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Abstract
Introduction In an increasingly diverse healthcare landscape, addressing the specific needs of Muslim patients has become paramount. The absence of comprehensive frameworks for Shariah-compliant healthcare services often poses challenges for healthcare professionals striving to provide care that aligns with Islamic values.
Objective The objective of this study was to develop a comprehensive framework for Shariah-compliant healthcare services, ensuring alignment with Islamic practices in healthcare.
Methods, setting, participants This consensus study employed a key input approach using the fuzzy Delphi method (FDM) and interpretive structural modelling. Conducted in Malaysia, the study involved 10 experts from various regions across the country. These experts were selected based on clear criteria that included professionals with experience in Islamic and/or healthcare, while those lacking relevant expertise were excluded.
Results The primary outcome was the identification of pertinent elements for the framework, with final elements measured based on expert consensus achieved through FDM. The panel of experts reached consensus on 10 essential elements that form the backbone of the framework for Shariah-compliant healthcare services. These elements include governance, medical ethics, patient care, human resources and professional development, facilities for Islamic worship (ibadah), spiritual care support, end-of-life care, Islamic environment, medicine and drugs, and affordability and accessibility.
Conclusion Ultimately, the development of this comprehensive framework is a crucial step in addressing the specific needs and concerns of Muslim patients worldwide. By incorporating the input and consensus of experts from various relevant fields, the resulting framework provides healthcare professionals with a solid foundation to deliver healthcare services that align with Islamic values, ultimately promoting the well-being of Muslim patients in Malaysia and tourists globally.
- Health Services
- HEALTH SERVICES ADMINISTRATION & MANAGEMENT
- Hospitals
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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Strengths and limitations of this study
Integration of fuzzy Delphi method and interpretive structural modelling provides a comprehensive approach to framework development.
Expert system approach adds robustness to the framework by incorporating advanced decision-making tools.
Focused on Shariah compliance, addressing a specific and significant need within the Malaysian healthcare context.
Addresses a niche area of Shariah-compliant healthcare, offering valuable insights for similar contexts.
The framework’s applicability might be constrained by regional healthcare variations outside Malaysia.
Introduction
The concept of Shariah (Islamic law) encompasses a comprehensive legal and ethical framework derived from the Quran and Hadith, governing various aspects of life, including healthcare.1 2 Shariah-compliant medical services (SCMSs) in this study context refer to healthcare practices that adhere to the ethical principles and requirements set by Islamic law,2 ensuring that services are aligned with Muslim beliefs, such as the prohibition of non-halal substances, respect for modesty and the provision of religious accommodations.3 Such services aim to integrate physical care with spiritual guidance to ensure holistic healthcare that meets the needs of Muslim patients.4
The increasing demand for SCMSs is influenced by global factors such as the rising Muslim population, economic growth in Muslim-majority countries and the global visibility of Islam.3 5–7 However, negative perceptions of Muslims worldwide, fueled by media portrayals and political rhetoric, have led to misunderstandings about Islamic values, including in healthcare.8 9 For instance, misconceptions about modesty requirements or halal dietary standards can lead to biased or inadequate care for Muslim patients, particularly in non-Muslim majority countries.10 11 These factors further emphasise the need for clear and formal standard guidelines that healthcare providers can follow to prevent misrepresentation and ensure high-quality care that respects religious and cultural needs.
Muslim patients often have unique spiritual and physical needs, such as gender-sensitive treatment options, access to halal-certified medications and spaces for prayer within healthcare facilities. Failure to accommodate these needs can result in dissatisfaction and suboptimal healthcare outcomes.5 12 13 Therefore, reconciling spiritual needs (eg, facilitating religious practices like prayer) with physical care (eg, providing halal medications and food and care) is crucial to delivering effective and culturally appropriate medical services for Muslim patients.14 15
Alongside Shariah-compliant services, terms such as Islamic medicine and Ibadah-friendly (facilitating religious practices during healthcare) have emerged. Islamic medicine is grounded in both classical Islamic texts and modern medical practices, emphasising the balance between physical and spiritual well-being.16 17 Meanwhile, Ibadah-friendly services specifically focus on enabling patients to perform essential religious duties, such as prayer and fasting, even while receiving medical care.14 Another important concept is Maqasid al-Shariah (objectives of Islamic law), which underpins the goal of healthcare by preserving life, intellect, lineage, wealth and faith.2 18
Malaysia’s healthcare system operates as a two-tier system, consisting of both public and private sectors. The public system, governed by the Ministry of Health (MOH), provides subsidised healthcare services to the general population, while the private sector caters more to medical tourists and is concentrated in the urban, affluent segments of society.19 20 In recent years, Malaysia has gained recognition as a leading destination for medical tourism, attracting a growing number of international patients seeking both conventional and Shariah-compliant healthcare services.6 21 The country’s multicultural demographic, where Muslims constitute around 61% of the population,22 23 highlights the importance of accommodating Islamic practices in healthcare settings. Given this background, the target population for Shariah-compliant healthcare services in Malaysia includes both local Muslim patients within the public healthcare system and international Muslim medical tourists who often opt for private hospitals offering specialised services. The increasing demand for SCMS in Malaysia is driven by this demographic, as well as the nation’s strategic position in the medical tourism sector.
Despite the growing interest in SCMS, Malaysia lacks formal standards or guidelines specifically designed for such services. The evolution of Shariah-compliant healthcare in Malaysia reflects efforts to integrate Islamic values with high medical standards to meet the needs of Muslim patients. The Ibadah-Friendly Hospital (IFH) concept, first introduced by Hospital Universiti Sains Malaysia (HUSM) in 1998 and officially launched in 2004, has been developed into a Shariah-compliant quality management system.24 25 This system prioritises patient well-being by incorporating ibadah (worship) practices into medical care during and after treatment. In recognition of these efforts, HUSM was awarded the Malaysian Standard (MS) 1900:2014 certification by the Standard and Industrial Research Institute of Malaysia in 2021.26 Al Islam Medical Centre has promoted this concept since 1996, focusing on aligning staff and administration with Shariah principles.14 The MOH further advanced the concept in 2010, formalising IFH certification for public hospitals with support from the Department of Islamic Development Malaysia (JAKIM).24 Additionally, hospitals such as Sultan Ahmad Shah Medical Centre @IIUM and An Nur Specialist Hospital have received MS 1900:2014 certification, reflecting their commitment to Shariah principles in healthcare management, including Halal food, patient segregation, prayer facilities and Shariah advisory committees.27 28 However, despite these developments, the field still faces challenges due to a lack of standardised guidelines. Existing standards such as the MS 1900:2014 focus on Shariah-based quality management systems but do not provide detailed guidance for medical services.29 While MS 1900:2014 ensures organisational management complies with Shariah principles, it does not address the holistic integration of Islamic ethics into medical procedures, patient care or religious sensitivities.
Previous research from countries such as Indonesia and Saudi Arabia has explored the integration of Shariah principles into hospital operations, highlighting various approaches adapted to their specific regional contexts. These studies demonstrate the diversity in implementing Shariah compliance but also reveal a critical gap: the absence of a universally applicable framework for ensuring consistent Shariah compliance across different settings, including Malaysia.30 31 To address this gap, the Islamic Hospital Consortium, initiated by the Federation of Islamic Medical Associations, has sought to establish Islamic hospitals in countries such as Indonesia, Pakistan, Jordan and Saudi Arabia.32 Although these hospitals are designed to incorporate Shariah principles, they operate without a standardised set of guidelines. This lack of uniformity further emphasises the need for a framework that can be consistently applied across various contexts.
In Malaysia, while initiatives such as the IFH concept represent progress, they often fall short of achieving comprehensive Shariah compliance. These initiatives primarily address religious obligations but do not fully integrate Shariah-compliant medical ethics and operational guidelines. This shortfall underscores the need for a more inclusive and systematic approach. Therefore, the proposed framework aims to fill this gap by providing a tailored, comprehensive solution for SCMS in Malaysia. By offering consistent guidelines that integrate both Shariah-compliant medical ethics and operational standards, the framework seeks to enhance patient experiences and advance the development of Shariah-compliant healthcare services in the country.
Materials and methods
The study design
The present study aimed to identify the most pertinent elements in developing SCMS through the application of two robust decision-making techniques: the fuzzy Delphi method (FDM) and interpretive structural modelling (ISM). These methods were chosen due to their ability to effectively incorporate subjective judgement and expert opinions in decision-making. The workshops for FDM and ISM were held at the end of 2022 and took place over three days and two nights. Data collection involved gathering expert opinions through structured questionnaires, while data analysis employed the FDM to reach consensus on key elements and ISM to establish relationships between these elements. The combination of these two techniques allowed the study to effectively identify the most pertinent elements in developing a framework for SCMS. The results of this study provide valuable insights for policy-makers, healthcare providers and researchers, ensuring that the developed framework is relevant and applicable across various fields of healthcare.
Fuzzy Delphi method
The selection of the FDM is justified by its capacity to address ambiguity and subjectivity while fostering expert consensus. FDM integrates fuzzy logic, which allows experts to provide nuanced evaluations rather than binary responses, making it ideal for interpreting the complex requirements of Shariah compliance in healthcare.33 This method efficiently incorporates diverse expert inputs and handles the uncertainty inherent in ethical and religious considerations, leading to a well-rounded and adaptable framework.34 35 The methodology’s ability to integrate multidisciplinary perspectives enhances the comprehensiveness of the developed framework, ensuring it is methodologically sound and applicable across various contexts.35 The use of fuzzy scales and defuzzification techniques further strengthens the analysis by systematically managing and quantifying expert feedback. The technique involves several steps, including the development of questionnaires, expert selection, linguistic scale determination, average calculation, threshold value identification, fuzzy evaluation aggregation and defuzzification process.33 36 37 The steps and process of FDM are as follows:
Questionnaire development
The development of the questionnaire for the FDM in creating an SCMS framework was based on preliminary research conducted by the research team. This included an extensive literature review and consultations with subject matter experts. Initially, 10 key elements and 34 subelements critical to Shariah compliance in healthcare were identified through a rigorous analysis of existing frameworks and scholarly discourse, ensuring a comprehensive representation of the relevant criteria. Following these, a detailed questionnaire was developed. This instrument used a 7-point linguistic scale to systematically capture the experts’ evaluations of the various elements deemed essential to the framework. This approach was designed to facilitate a nuanced assessment of Shariah compliance and to ensure that the framework accurately reflects the experts’ perspectives on the key elements.
Expert selection
Expert selection was a crucial aspect of the FDM, with 13 experts initially chosen based on their knowledge of the subject matter, experience in related fields, willingness to fully participate, interest in the study’s success and clear communication skills (refer table 1). Of these, 10 experts consented to join the study. They represented diverse fields such as medicine, policy-making, Islamic scholarship, academia and non-governmental organisations, ensuring a well-rounded approach to the research. This selection of experts is justified by their respective fields of expertise and how their contributions aid in the development of a comprehensive and Shariah-compliant healthcare framework.
Panel of experts selected for the study
The selection of these experts was crucial to ensuring that the development of the SCMS framework was comprehensive and well-informed. Each expert brought specialised knowledge from their respective fields, enabling a multidisciplinary approach to addressing the complex intersection of healthcare and Islamic principles. The inclusion of a policy-maker from the MoH ensures that the framework is grounded in existing regulations, facilitating its potential integration into the national healthcare system. Medical professionals and hospital directors contributed practical insights on the operational challenges of implementing Shariah-compliant practices in both public and private healthcare settings. Additionally, representatives from the Malaysian Medical Council and NGOs provided perspectives on ethical standards, patient rights and community needs, which are essential for ensuring the framework’s applicability and acceptance.
The participation of academics with expertise in Islamic law, bioethics and spiritual care further strengthened the framework by addressing legal, ethical and psychospiritual dimensions, ensuring a holistic approach. Their knowledge of Islamic jurisprudence and healthcare ethics was pivotal in shaping a framework that aligns with Islamic principles while maintaining high standards of medical practice. This diverse panel of experts, with their combined expertise, was instrumental in ensuring that the proposed framework is both practical for healthcare providers and reflective of Islamic values, making it suitable for implementation in a variety of healthcare settings.
Linguistic scale determination
A 7-point scale was chosen to express expert opinions, ranging from ‘extremely not important’ to ‘extremely important’. The scale used triangular fuzzy numbers (TFNs) to represent degrees of uncertainty. The TFN was defined by three values: minimum (m1), most probable (m2) and maximum (m3), as illustrated in table 2.
Linguistic scale for fuzzy Delphi method questionnaire
The experts’ responses, accompanied by the corresponding fuzzy number scales for each questionnaire item related to their perception of the important element in establishing an SCMS, were recorded in an Excel spreadsheet.
Data collection and average calculation
Expert responses were collected and organised using the linguistic scale. A key step in the FDM process is calculating the average values of m1, m2 and m3 from the experts’ evaluations, which represent the collective opinion of the experts. To determine the threshold value (d), the difference between each expert’s evaluation and the average value is calculated using the formula:
In this formula, m1, m2 and m3 represent the average opinions of all experts, while n1, n2 and n3 represent the fuzzy values given by each expert for the three values. The threshold value, d, is essential in assessing the level of consensus among experts, as it measures the agreement between their evaluations. Cheng and Lin suggest that a threshold value of 0.2 or less indicates consensus among the experts.38 However, to ensure the validity of the decision-making process, the overall consensus must exceed 75%. If the consensus is below this threshold, a subsequent round of FDM may be required to achieve adequate expert agreement. This 75% consensus threshold is crucial for ensuring the reliability and accuracy of the results.
Fuzzy evaluation aggregation
The fuzzy evaluations provided by experts were aggregated to form a collective assessment. This step involved summing the fuzzy numbers for each item to determine the overall evaluation.
Defuzzification
The final step involved converting fuzzy evaluations into crisp values to rank the variables. The defuzzification value indicated the level of expert agreement. These values range from 0 to 1, reflecting the level of agreement on a particular element or subelement. A defuzzification value between 0.00 and 0.50 indicates low consensus, suggesting the element may not be suitable for inclusion. Values between 0.51 and 0.74 represent moderate agreement, indicating the need for further refinement. Values from 0.75 to 1.00 show strong consensus, marking the element as important and were included in the final framework. FDM’s structured methodology ensures a rigorous approach to synthesising expert opinions, addressing the complexities of SCMS.
Interpretive structural modelling
The application of ISM was crucial following the FDM analysis, as it provided a structured understanding of the interrelationships between elements identified through the FDM. ISM is a method specifically designed to deal with complex issues by structuring expert insights and forming a hierarchy of elements, which is particularly relevant for developing an SCMS framework. This methodology enables the modelling of relationships between key elements, ensuring a clear depiction of which factors are foundational for others. ISM allows for the visualisation of interdependencies, aiding in effective decision-making and strategy development.39 40 The structured mapping derived from ISM complements the consensus-building nature of FDM by translating expert opinions into actionable strategies, ensuring a more robust and implementable framework. Combining FDM with ISM provides a systematic and multilayered approach, ensuring not only the identification of key elements but also their structured implementation.
In the ISM approach, the initial step involved the identification of variables relevant to the problem under investigation. This study specifically focused on ten agreed on elements, as outlined in table 3. To establish meaningful connections between these elements based on contextual considerations, contextual relationship expressions were identified. The integration of indicators and generation of the ISM model were primarily guided by the input of experts. Consensus experts provided advice on determining contextual relationships and relationship expressions, which elucidated how the elements should be interconnected. Specifically, the chosen contextual phrase for this study was ‘In establishing a Shariah-Compliant Healthcare Service in Malaysia,’ while the relationship phrase used was ‘MUST be managed BEFORE’ (interpreted as arrow signs).
Threshold values (d), expert agreement (%) and defuzzification value (A) for each element and subelement in the Shariah-compliant medical services framework
Next, the Structural Self-Interaction Matrix (SSIM) was developed through a pairwise comparison of variables and transitive logic. The ISM software played a crucial role in this process, as it facilitated the presentation of pairs of elements to experts, enabling them to vote on the relationships between each pair. Only after voting on a pair was completed did the software display the next pair of elements for evaluation. This iterative process continued until all elements had been considered. Following the development of the SSIM, the ISM model was constructed. The software automatically generated this structural model based on intelligent pairwise comparisons and transitive logic. The concept of transitive logic suggests that if element A is related to element B (A → B) and element B is related to element C (B → C), then element A is linked to element C (A → C or A → B → C).
The constructed ISM model underwent an expert review process. During this stage, experts carefully examined the model to identify any conceptual inconsistencies and recommended necessary modifications. However, it is important to note that only minor modifications were permitted, as the structure of the model had been developed through a systematic process involving extensive discussions and arguments. The modifications made during this review stage do not challenge the overall structure of the ISM model.41
Finally, the ISM model was evaluated using the MICMAC (Multiplication Impact Matrix of Multiple Applied Classification) analysis method originally proposed by Godet (1973) as cited in Ahmad et al.42 Through this analysis, the variables within the model were classified into clusters based on their power and dependence. The resulting classification facilitated the analysis and interpretation of data, allowing for a better understanding of the importance and hierarchical relationships among the elements linked to the Shariah-compliant hospital service proposed framework.
The FDM mitigates individual biases through anonymous feedback, facilitating a consensus that reflects diverse expert opinions rather than the influence of any single individual.33 Similarly, ISM offers a structured framework for analysing complex relationships among variables, reducing the risk of disproportionate influence by integrating multiple stakeholder perspectives.40 Both methods collectively enhance the study’s reliability and validity by ensuring that the findings are based on a balanced and comprehensive assessment.
Patient and public involvement
None.
Results
In the process of evaluating the important element in developing a framework for SCMS, a comprehensive questionnaire for FDM was devised using linguistic scale. The FDM questionnaire consisted of 10 elements and 34 subelements, which were tabulated in table 3. The analysis of the FDM revealed that the threshold values (d) for all elements and subelements were below 0.2, indicating a high level of agreement among the expert participants regarding the proposed elements and subelements. The overall group consensus was 88%, with all elements and subelements attaining expert consensus (75% agreement among experts) except for subelement number 20, which received only 30% expert agreement. As a result, subelement number 20 (staff welfare care and protection, such as partially funded haj and weddings) was omitted from further consideration. The defuzzification process was used to rank each element, with the results presented in table 3. The results showed a high level of consensus among the experts regarding the important element in developing a framework for SCMS, as determined by the low threshold values and high overall group consensus.
The presented figure illustrates (figure 1) the proposed framework for SCMS. Consistent with the findings from FDM, the proposed framework demonstrates that governance emerged as the most crucial element, followed by medical ethics and other associated elements. The proposed framework highlights that, in the context of implementing a sustainable Shariah-compliant healthcare service in Malaysia, the prioritised elements must be effectively managed before the subsequent elements. For instance, the governance of the hospital must be established as a priority before addressing medical ethics to ensure a sustainable Shariah-compliant healthcare service. Based on the MICMAC analysis, the elements classified as independent are governance, medical ethics, patient care, human resource and professional development, and medicine and drugs. These elements are identified as primary driving forces in the implementation of SCMS in Malaysia. Feedback from experts indicates that these elements align with standard management components observed in existing hospital management structures. In contrast, the elements identified as dependent include ibadah facilities, spiritual care support, affordability and accessibility, Islamic environment and end-of-life care. These elements rely on the effective implementation of other components for their success. Experts concurred that these elements embody the distinctive features of Shariah-compliant management and are crucial for the establishment or conversion of general hospitals into Shariah-compliant healthcare facilities.
Proposed framework for Shariah-compliant medical service.
Discussion
Based on previous research and the discussions throughout the study, the experts arrived at a definition of SCMS as medical services provided by healthcare facilities that align with the principles of Shariah and cater to the needs of patients. The establishment of these healthcare institutions must be rooted in the protection of the Maqasid al-Shariah, and the entire ecosystem of the healthcare institution must comply with Islamic principles. This study presents a comprehensive framework for the provision of SCMS, which encompasses ten critical elements: governance, medical ethics, patient care, human resources and professional development, ibadah facility, spiritual care support, end-of-life care, Islamic environment, medicine and drugs, and affordability and accessibility. This comprehensive guide serves as a foundation for setting standards in SCMS and ensuring that medical practices align with Islamic principles and values. The framework provides a thorough and systematic approach to addressing the needs of Muslim patients and ensuring that medical services are in line with Islamic principle and beliefs.
Governance
The FDM results highlight key governance components for SCMS, such as management commitment, Shariah panels, task forces, Maqasid Shariah-based governance and clear Standard Operating Procedures (SOPs). This consensus risks redundancy if not distinguished from existing practices in the current Malaysian medical services setting. For instance, many medical services already adhere to ethical frameworks and include committees for compliance, although not labelled as Shariah-compliant. To make a difference, Shariah panels must play a more active role in decision-making, beyond symbolic functions.14 The task force for Shariah conformity also needs real authority to enforce compliance effectively, avoiding overlap with existing regulatory bodies.27 Maqasid Shariah-based governance offers a broad ethical framework, but its real impact depends on its practical application in clinical settings, such as decisions on patient care and resource allocation.5 43 Without concrete guidance, it risks being merely theoretical. Similarly, while clear SOPs are vital, they must introduce unique Islamic guidelines beyond what already exists in public hospitals, addressing Islamic law in complex medical scenarios.28 Thus, these proposed governance elements must provide actionable, enforceable distinctions to elevate SCMS beyond mere labelling.
Medical ethics
The findings on medical ethics for SCMS framework emphasise providing services that align with both Islamic principles and established medical ethics, as well as ensuring the protection of patient confidentiality, safety and security. However, this consensus risk being perceived as general and redundant, particularly when considering that such practices are already embedded in most of the hospitals under secular ethical standards. In Malaysian hospitals, patient safety, confidentiality and ethical medical practices are regulated by existing accreditation body of Malaysian Society for Quality in Health since 1997.44 These are universally applicable, regardless of religious context. Therefore, for Shariah-compliant healthcare services to be distinct, they must integrate Shariah principles that extend beyond these universal practices. For example, while client confidentiality is already a legal requirement, the Shariah-compliant approach may additionally focus on the protection of dignity according to Islamic teachings, particularly in gender-sensitive situations such as medical examinations involving male and female interactions.4 Similarly, the concept of ‘Amanah’ (trust) could be emphasised in relation to the handling of patient information, ensuring that confidentiality is not only maintained from a legal perspective but also framed as a religious duty. The protection of patient safety within Shariah-compliant healthcare could incorporate a more holistic approach, recognising the Maqasid Shariah, which emphasises the protection of life and well-being.14 This could involve additional measures, such as the provision of spiritual support during treatment, which is not commonly included in current medical ethics but is a key feature of Islamic healthcare.45 The distinctiveness of SCMS framework lies in its integration of both ethical and religious principles, which should be operationalised through more specific, culturally and religiously sensitive guidelines. Without this distinction, the recommendations risk merely reiterating practices that already exist within Malaysian hospitals, thus diluting their intended impact.
Patient care
The agreement on element of patient care in SCMS framework emphasises maintaining high standards of medical care, fostering positive relationships between healthcare professionals and patients (muamalah) and ensuring patient dignity. While these elements are critical, their distinction from existing practices in Malaysian hospitals must be clarified to demonstrate their unique contribution to Shariah compliance. The agreement for maintaining high standards of medical care is consistent with universal healthcare objectives but lacks a Shariah-specific dimension. For example, while ensuring quality care is crucial, Shariah compliance would benefit from explicitly incorporating Islamic principles like ‘Adl’ (justice) and ‘Ihsan’ (excellence).14 This could involve developing clinical protocols that ensure fairness and high ethical standards in patient treatment and decision-making processes,5 46 thus distinguishing Shariah-compliant services from general healthcare practices.
Additionally, current practices in Malaysian hospitals may focus on clinical excellence but do not necessarily integrate the ethical depth of Islamic teachings. A Shariah-compliant framework could include guidelines on how to balance clinical efficacy with ethical considerations such as equitable access to care and compassionate patient interactions, providing a more comprehensive approach that aligns with Islamic values.27 Similarly, while muamalah (relationships between healthcare professionals and patients) is highlighted as important, it requires a deeper integration of Islamic ethics. This involves developing targeted training programmes for healthcare professionals that emphasise the ethical dimensions of patient interactions according to Islamic teachings.28 Without such integration, the concept risks being seen as a general professional courtesy rather than a distinctive Shariah-compliant practice.
The focus on patient dignity, including gender sensitivity and privacy, is already addressed within Malaysian healthcare. However, Shariah compliance demands additional Islamic considerations. This could involve specific protocols for managing gender interactions and sensitive procedures in a manner that adheres to Islamic norms.31 Current practices, while addressing privacy, may not fully reflect the nuanced requirements of Islamic ethics. While the recommendations on patient care align with essential healthcare principles, their distinctiveness in this framework lies in the incorporation of specific Islamic values and guidelines. This ensures that SCMSs that follow the framework not only adhere to general healthcare standards but also provide a unique, ethically grounded approach to patient care.
Human resources and professional development
The high consensus on the element of Human Resource and Professional Development in this study suggests several areas for improvement to ensure alignment with SCMS. These include ensuring that healthcare professionals are qualified, providing systematic training and implementing Shariah-compliant policies. Ensuring the qualification and competence of healthcare professionals is fundamental to any healthcare system.47 However, for Shariah-compliant healthcare, this should also involve integrating Islamic values into professional development. This means not only meeting medical qualifications but also adhering to ethical standards that reflect Islamic principles, such as honesty and integrity in patient care.14 28 The recommendation to provide systematic and ongoing training for healthcare workers is crucial for maintaining high standards. To make this Shariah-specific, training programmes should incorporate Islamic ethics and principles. For example, courses could include modules on Islamic bioethics, which address issues like patient consent and confidentiality from a Shariah perspective.4 48 This would help bridge the gap between general healthcare practices and Shariah compliance.
Similarly, periodic awareness training on SCMS for employees is essential. However, it is important to ensure that such training goes beyond basic awareness and includes practical guidance on implementing Islamic principles in day-to-day operations.14 This could involve developing case studies or scenarios that illustrate how Islamic principles should be applied in various clinical situations. The execution of Shariah-compliant service policies among employees is a crucial step in aligning healthcare practices with Islamic teachings. Effective implementation requires clear guidelines and consistent enforcement, ensuring that all staff understand and adhere to these policies.5 28 49 For instance, policies should be detailed and practical, covering areas such as ethical patient interactions and compliance with Islamic principles in medical decision-making.
The rejection of staff welfare care elements, such as subsidised Hajj and weddings, highlights a potential misalignment with the practical needs of healthcare workers. While such welfare measures are valuable, their direct impact on Shariah compliance might be less significant compared with other aspects like professional training and policy adherence. Focusing on more directly impactful measures, such as specific Shariah-compliant training and policy execution, may offer clearer benefits in aligning with Islamic principles.5 By ensuring that healthcare professionals are not only qualified but also trained in Islamic medical ethics, and by enforcing Shariah-compliant policies on staff conduct and attire, this proposed framework can offer a unique blend of professional excellence and religious observance that goes beyond the standard practices of conventional healthcare institutions.
Ibadah facilities
The results also highlight the important element of Ibadah facilities but reveal gaps in their practical application and differentiation from current setting practices. The agreement to provide basic facilities such as prayer rooms and tayammum equipment aligns with Islamic principles, yet it often lacks the specificity required for effective implementation. While many medical services offer prayer spaces, they may not fully support all aspects of Islamic ritual practices, such as tayammum. A truly Shariah-compliant framework should include precise guidelines and ensure these facilities meet comprehensive Islamic standards.14 50 Similarly, providing clear guidelines through guidebooks and apps is a step in the right direction, but current resources are often insufficiently detailed and may not address diverse patient needs effectively.28 For example, guidelines should explicitly detail how to use facilities for Islamic rituals in a healthcare context, which is often missing. Ease of accessibility is crucial, yet existing hospital facilities may not adequately address accessibility for all patients, particularly those with mobility issues. Simply having prayer rooms does not guarantee that they are accessible or adequately equipped for all patients, which is a significant oversight in current setting.14 To genuinely enhance Shariah compliance, more specific details and deeper integration of Islamic principles into healthcare facilities are required, beyond current general provisions.
Spiritual care support
The high consensus for spiritual care support underscores their critical role in addressing patients’ holistic needs. Despite recognition of spiritual care’s importance, its informal practice in healthcare setting often limits its effectiveness.51 The proposed framework would address this gap by aligning services with Islamic values, ensuring a more structured approach to spiritual care. The consensus to have a management department also emphasises the necessity for dedicated oversight. Currently, spiritual care in Malaysian hospitals is often provided without formal labelling as ‘Islamic’, which limits its impact.14 By creating a dedicated spiritual care department, the framework would ensure clearer guidelines and greater consistency in service delivery, fostering integration of Islamic principles into patient care. Training for staff further highlights the importance of developing healthcare providers’ competencies in delivering spiritual care. Research shows that most Malaysian nurses possess only average competence in spiritual care, with structured training proving to be an effective solution.52 53 By incorporating systematic training into the proposed framework, staff will be better equipped to deliver high-quality, Islamic-based spiritual support. This framework not only formalises spiritual services but enhances them to ensure they are both structured and aligned with the spiritual needs of Muslim patients.
End-of-life care
The state of end-of-life care in Malaysian healthcare setting faces several challenges, including limited palliative care services, cultural barriers and ethical inconsistencies. Only 25.8% of public hospitals offer formal palliative care, with a shortage of specialists,54 and many patients, especially those with end-stage diseases, lack awareness of end-of-life options.55 The acceptance of subelements like task force committees, Talqin (reciting shahadah), do not resuscitate (DNR) consent, and organ donation in this study requires greater focus on practical application and religious alignment within SCMS frameworks. A dedicated Task Force Committee for end-of-life care could incorporate Islamic jurisprudence into decision-making, providing religious oversight that addresses ethical conflicts more effectively than existing ethics committees.14 However, it must avoid duplicating existing efforts and show how it offers distinct improvements. Similarly, incorporating Talqin (reciting shahadah) at death is a unique addition, but its implementation in a time-sensitive hospital environment requires clear guidelines to avoid disrupting medical care while meeting spiritual needs.
The recommendation for DNR consent from an Islamic perspective should clarify the religious uncertainties in current practices. Although DNR policies are already in place, integrating Shariah guidance could improve communication and bridge the understanding gap between medical staff and Muslim families.56 For brain death and organ donation, while protocols exist, Muslim patients often resist due to uncertainty regarding Islamic rulings. A Shariah-compliant framework can provide clear religious rulings, such as the Fatwa Council’s stance on brain death and organ donation, increasing trust and participation.57 This proposed framework extend beyond mere relabelling of existing practices, it necessitates a profound integration of Islamic perspectives into clinical decision-making processes. Such integration is essential to comprehensively address the spiritual needs of patients within end-of-life care, ensuring that these needs are fully met in accordance with Islamic principles.
Islamic environment
The element of Islamic environment emphasises integrating Islamic practices more thoroughly into healthcare operations. While some practices are present in Malaysian medical settings, they remain largely informal. The subelement of an Islamic social atmosphere could formalise rituals such as daily prayers, the call to prayer (azan) and Qur'anic and Dua recitation over the hospital’s PA system.4 Staff could be trained to greet patients with Salam consistently, fostering a spiritually aligned environment. Additionally, reciting Bismillah before medical procedures would emphasise the connection between faith and healthcare, embedding these practices in daily operations.14 Continuous awareness programmes, supported by 90% agreement, could include regular tazkirah (religious reminders) and usrah (Islamic study groups) for both patients and staff.28 46 These programmes could address topics like the importance of Sabr (patience) in healing or the spiritual significance of illness, reinforcing Islamic values in care settings. The inculcation of Islamic practices, such as zakat (charity) and congregational prayers, would systematise acts like sadaqah and ensure that prayer facilities are easily accessible. These efforts go beyond offering prayer rooms or charity options, embedding these acts as essential components of hospital services.14 27 This proposed framework could transform the healthcare institution into environments that actively promote Islamic principles, enhancing both spiritual and medical care.
Medicine and drugs
The result also emphasises the element of medicine and drugs, specifically in the prescription of Halal-certified medicines (weightage 0.128) and the establishment of procurement SOPs (weightage 0.107). Although Halal-certified medicines are used in some Malaysian healthcare setting, the absence of formal standardisation and effective patient communication significantly limits their impact. The lack of a unified framework for Halal certification creates inconsistencies across hospitals and clinics, leading to confusion among healthcare providers and patients.6 7 Additionally, the failure to communicate the Halal status of prescribed medicines leaves patients unsure whether their treatments align with Shariah principles, further eroded by issues like fake Halal logos.58
Addressing the challenge of Halal medication availability is crucial. If a hospital faces difficulties in sourcing Halal-certified medications due to limited availability, it does not necessarily render the hospital non-Shariah compliant. Instead, this highlights the need for practical solutions to uphold Shariah principles as closely as possible. Implementing a structured SOP for procurement is essential. Hospitals should prioritise the use of Halal-certified medicines when available, document their efforts and seek alternatives or expert guidance when Halal options are not accessible.6 59 Engaging with suppliers to increase Halal-certified options and establishing transparent policies will enhance adherence to Shariah principles.
Current legal frameworks do not adequately address the complexities of Halal certification in pharmaceuticals, necessitating a comprehensive review to protect consumers.60 The growing demand for Halal products highlights the need for a cohesive strategy and effective communication. Implementing a structured SOP for procurement can significantly enhance adherence to Shariah principles by ensuring all drug-related decisions are consistently aligned with these standards. This approach would address the incidental compliance seen in many conventional hospitals, reducing inefficiencies and ambiguities.5 Regular audits and targeted staff training on Shariah compliance would further enhance transparency and accountability, setting SCMS apart from their conventional counterparts.
Affordability and accessibility
The findings also highlight elements of affordability and accessibility in SCMS framework. Key aspects include reasonable medical costs, transparent pricing policies and collaboration with Islamic funding agencies such as wakaf, zakat and Baitulmal. While Malaysian public hospitals already offer subsidies and financial aid, a more targeted approach involves formal partnerships with these Islamic agencies to directly address healthcare needs.59 For example, integrating wakaf to fund specific treatments or medical equipment could provide significant financial relief and align with Islamic principles.
However, current collaborations between Islamic funding bodies and hospitals are often limited and underutilised. Formalising these partnerships and establishing clear policies on fund distribution could improve healthcare accessibility for financially vulnerable patients. Transparency in medical costing is also vital to ensure fairness and alignment with Shariah principles, as some hospitals lack itemised billing, leading to mistrust.14 59 Although existing healthcare systems in Malaysia address affordability, this SCMS framework could further refine this with culturally and religiously aligned practices. For instance, establishing funds within hospitals for zakat or wakaf could enhance financial support, differentiating SCMS from conventional systems. This structured approach not only aligns with Islamic ethics but also sets a new standard for fairness and accessibility in healthcare.
Implications of the Shariah-compliant medical framework
The study highlights several pivotal aspects of the SCMS framework, underscoring its importance for effective healthcare delivery in Malaysia. The framework’s alignment with Shariah principles ensures adherence to ethical standards, addressing the fundamental need for moral integrity in medical practices. This alignment is supported by prior research, which emphasises that ethical guidelines are crucial for improving patient outcomes and satisfaction.61 However, while the framework promotes ethical practices, it must remain adaptable to individual patient needs to avoid overly rigid constraints that could hinder personalised care.62
In the context of the Malaysian healthcare system, which is characterised by a blend of public and private sectors with varying degrees of Shariah compliance, the framework’s role in fostering cultural and religious inclusivity is particularly significant. Malaysia’s healthcare system serves a diverse population, including a substantial Muslim demographic whose needs can be effectively addressed by Shariah-compliant practices. Moreover, the framework’s emphasis on key components such as governance, medical ethics, patient care, human resource development and the management of medicine and drugs is crucial for ensuring that healthcare services adhere to Shariah principles while addressing practical needs. This focus is particularly relevant given the ongoing efforts in Malaysia to integrate Shariah compliance into various aspects of public and private healthcare.24 59
Considering the current landscape of the Malaysian healthcare system, which includes well-established public health facilities and a growing private sector, the framework’s large-scale implementation presents both opportunities and challenges. Public health facilities in Malaysia are often governed by established practices and regulations, while private facilities may have more flexibility in adopting new frameworks. Integrating a Shariah-compliant framework into this mixed landscape requires a nuanced approach that balances adherence to Shariah principles with the operational realities of existing healthcare systems. A phased implementation strategy would be essential to incorporate Shariah-compliant practices gradually without disrupting existing services. Pilot programmes within both public and private sectors can provide valuable insights and facilitate adjustments based on practical feedback. Additionally, engaging stakeholders across the healthcare system, including policy-makers, healthcare providers and patients, is crucial to ensure the framework’s effective integration. Training healthcare providers on Shariah principles and their application in medical contexts is also vital. This training ensures that staff members across various healthcare settings are equipped to implement the framework effectively, promoting consistency in care delivery and adherence to ethical standards.
Furthermore, as Malaysia increasingly positions itself as a hub for medical tourism, particularly among Muslim patients from neighbouring countries, the Shariah-compliant framework could serve as a unique selling point. Offering Shariah-compliant healthcare services could attract a broader clientele seeking both high-quality medical treatment and services that align with Islamic values. The growing demand for medical tourism positions the framework as a strategic advantage in appealing to international patients, further strengthening the country’s healthcare sector.
Limitations of the study
This study presents several limitations that must be considered when interpreting the findings. First, the research focuses exclusively on the conceptualisation of a framework for SCMS in Malaysia. As a result, it does not address peripheral issues or additional elements that may indirectly influence the successful implementation of the framework. This narrow scope may limit the comprehensiveness of the framework by omitting relevant external factors. Second, the methodology employed, specifically the FDM, relies heavily on the subjective opinions of selected experts. While expert input is valuable, this approach may introduce biases, as the findings are shaped by the perspectives of a purposively sampled group. This limits the generalisability of the results, as the expert consensus may not fully represent the broader population of healthcare professionals or other stakeholders. Moreover, the purposive sampling technique, while effective for selecting participants with specific expertise, restricts the applicability of the findings beyond the healthcare sector. This suggests that the proposed framework may not be suitable for other industries or contexts outside of Malaysia, thereby reducing its broader relevance. Lastly, the framework developed in this study is still in its preliminary stages. It requires further refinement through continuous engagement with a broader range of stakeholders and deeper validation through empirical research. Therefore, it would be premature to claim that this framework is ready to be implemented as a comprehensive guide for healthcare providers. Rather, it should be seen as an initial step toward the development of a fully operational SCMS framework.
Conclusions
The development of an SCMS framework in Malaysia, using both the FDM and ISM, represents an important step in addressing the healthcare needs of Muslim patients. This study successfully identified 10 essential elements, such as governance, medical ethics, patient care, human resource management and Islamic environment, that are critical for delivering comprehensive Shariah-compliant healthcare. By achieving expert consensus through these structured methodologies, the framework aligns healthcare services with Islamic principles, promoting both physical and spiritual well-being for Muslim patients. The integration of FDM and ISM ensured a methodical, expert-driven approach, highlighting not only the importance of each element but also their interrelationships, especially the prioritisation of core aspects like governance and medical ethics in enabling successful implementation of other components, such as ibadah facilities and spiritual care. This structured approach strengthens the framework’s validity and applicability within Malaysia. However, while this framework is tailored to Malaysia’s healthcare system and demographic needs, its wider applicability may be limited by regional variations in healthcare practices and resources. Nonetheless, it offers a foundational tool for developing more universally applicable standards in Shariah-compliant healthcare. Future research could explore its adaptability to different cultural and regional contexts, promoting a more inclusive understanding of Muslim patients’ needs on a global scale.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and this study adhered to ethical guidelines, with informed consent obtained from all participants through written consent. Participation was voluntary, and participants had the right to withdraw at any time without consequences. Confidentiality was maintained by anonymising data and securely storing it. Ethical approval for the study was obtained from the Ethics Committee of Universiti Teknologi PETRONAS’s Research Management Centre (Approval No. 015MA0-111), ensuring compliance with established research standards. Participants gave informed consent to participate in the study before taking part.
Acknowledgments
We extend our sincerest appreciation to the distinguished expert participants who have graciously devoted their time, knowledge and perspectives to ensure the success of this study. Their significant contributions have been vital in determining the trajectory and outcomes of the project. Furthermore, we would like to express our gratitude to the grant providers who have provided financial support to this endeavour. Their generous support was imperative for the realisation of this study, and we are thankful for their belief in our team and the objectives of the study. We extend our heartfelt thanks to all those who have been instrumental in making this study a reality.
References
Footnotes
Contributors All authors contributed meaningfully to the research and preparation of this manuscript. FICJ was responsible for writing the manuscript, data collection, analysis and interpretation of findings. MRTLA contributed to the conception and design of the study, data collection, analysis, interpretation of findings and critically revising the manuscript. MNAAE also contributed to the conception and design of the study, data collection, analysis, interpretation of findings and critically revising the manuscript. SMS was involved in data collection, analysis, interpretation of findings and critically revising the manuscript. KAH contributed to the conception and design of the study, as well as data collection and analysis. SH contributed to the conception and design of the study, along with data collection and analysis. Guarantor statement: FICJ is the guarantor. This manuscript was proofread using AI-based language processing tools to enhance clarity, grammar and overall readability. The AI tools assisted in refining sentence structure, correcting typographical errors and ensuring consistency in formatting. However, the authors took full responsibility for the content, interpretation of the data and conclusions presented in the manuscript.
Funding This research was supported by funding from the FRGS (Fund for Research Grant Scheme) under grant numbers FRGS/1/2020/SS0/UTP/02/1, Yayasan UTP (YUTP-FRG 1/2021/ 015LC0-356), Universiti Kuala Lumpur (UniKL) under grant number 015MC0-017 and the National Collaborative Research Fund under grant number 015MD0-095.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.