MALAYSIAN HEALTHCARE SYSTEM

TOWARDS ACHIEVING BETTER HEALTH

CARE FOR MALAYSIA

Dr. Abd. Rahim bin Mohamad Planning and Development

28 September 2010 Putrajaya

Welcome Selamat Datang, Salam Eidil Fitri

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  Consultants- lecturers   Paticipants

• Engineers • Architects • Doctors- consultants • Medical Planners • Managers

Presentation Outline   Ministry of Health

  Vision & Mission & Challenges   Problem Statement & Issues   Current Health System

  Transforming the Nation   The Proposed 1Care Model for Malaysia   Phases of Development & Financing

  Implications   RMK-10 Strategic Plan   Conclusion 3

MINISTRY OF HEALTH

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Other Govt Agency

University, MOE, Youth &

Sports

MOH

Consumers Elderly, Youth,

Children

International WHO,

UNICEF, UNDP Private Sector

GPs, Private Hospitals, TCM,

NGO MMA,

PPIM,MOPI,

MINISTRY OF HEALTH

  Technical Ministry   Punctuality   Fast Services   Evidenced based   Caring   Professionalism   Teamwork

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Corporate Culture

Vision & Mission

Vision   A nation working together for better health

Mission   The mission of the Ministry of Health is to lead and

work in partnership: i. to facilitate and support the people to:

•  attain fully their potential in health •  appreciate health as a valuable asset •  take individual responsibility and positive action

for their health 6

ii. to ensure a high quality health system that is: •  customer centred •  equitable •  affordable •  efficient •  technologically appropriate •  environmentally adaptable •  innovative

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CHALLENGE

In order to achieve Vision 2020, Malaysia needs to become a country of high income economy.

To achieve the lowest limit for a high income nation, Malaysia has to make at least 5.5%

yearly growth

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PROBLEM STATEMENTS

  Issues raised concerning public medical services •  Long waiting time •  Postponed cases • Overworked staff in 3rd class wards –

impersonal….. •  Lack of choice •  Inadequate amenities

  Issues raised concerning private sector •  Exorbitant charges •  Increasing private insurance premium •  Appropriateness of care vs. overservicing

PROBLEM STATEMENTS 2

  National Health Account Study 2006 •  Out-of-pocket (OOP) spending in Malaysia is high (40% of THE)

•  RM 9805 million •  OOP spending in developed countries is low <20%

  Equity •  High cost private healthcare– available only to those who can afford,

insured or covered by employer •  Fairness in financing – high OOP payment (inequitable financing and

can lead to impoverishment due to catastrophic health expenditure)

  Economics •  More efficient use of resources (especially HR)

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CURRENT ISSUES-1

1. Highly subsidised services & overdependence on government health facilities (also patronised by those who can afford)   Heavy workload   Long waiting time

2. Inadequate integration in health, especially between public & private sectors   “Brain drain” to private sector – non-optimal resource use   Need for better regulation of private healthcare providers   Fragmented care and clinical record

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CURRENT ISSUES-2

3. Rising healthcare expenditure •  rising demand and expectations •  expensive high tech medicine/equipments

4. “Gaps” in present healthcare delivery system eg. Equity, efficiency, accessibility, quality of

service. 5. Changing demographic &

epidemiological patterns   Increase in the ageing population   Increase in chronic diseases

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CURRENT ISSUES-3

6. Increasing healthcare charges in private sector   Greater inequity & public outcry if not controlled   Increasing trend of private health expenditure

(esp. Out-of-pocket expenditure – financial risk upon unexpected health events)

  ‘Supplier-induced demand’   Equity in access to private sector

 Physical : Concentrated in urban areas  Financial : Access to private services is mainly for those who can afford esp. inpatient care

Current Functions of MOH Within the dual health care system, MOH is Funder, Provider and Regulator   Health Policies & Planning   Public Health Activities

•  Communicable Disease •  Non-communicable Disease

  Regulation & Enforcement •  Personal care •  Public Health •  Pharmacy •  Technology •  Medical Devices

  Monitoring & Evaluation •  Quality Assurance •  Health Technology Assessment •  Patient Safety •  Guidelines and Standards

  Training   Research & Development

  Primary Care Services •  Out-patient services •  Maternal & Child Health •  Health Education •  Home Visits & School Health

  Secondary & Tertiary Services •  In-patient services •  Specialist care

  Pharmaceutical Services   Oral Health Services   Imaging and Diagnostics   Laboratory Services   Telehealth & Teleprimary care   Health Information Management

Basic Health Services

Number Beds   Hospitals 130 33,083   Special Medical 6 4,974 Institutions(SMI)   Special Institutions 6 (PDN,PHLab)   Non –MOH Hosp 8 3,523   Private hospitals 209 12,216   Private maternity home 21 102   Private Nursing Home 12 273

Health Facts 2009

Basic Health Services

Number   Health Clinic(KK) 808   Community Clinic(KD) 1,920   Maternal &Child Clinic 90   Mobile Health Clinic 196   KKM Dental Clinic 1,724 (2,952 dental chairs)   KKM Mobile Dental Clinic 560 (1,392 dental chairs)   Private GPs 6,307   Private Dental Clinics 1,484

Health Facts 2009

OPD & Hosp.Admissions(1997-2009)

* Excludes 9.6m Dental cases& 12,316,350 MCH attendances

Public & Private Sector Resources and Workload (2008)

19 Source: Health Informatics Center (HIC),MOH

11%

38%

41%

78%

74%

55%

45%

Public Private Expenditure on Health, 1997-2007 (2007 RM Value)

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5,616 5,806 6,351

7,320

8,727 9,083

12,067 11,558

10,271

11,542

13,546

5,658 5,538

5,970

6,571 6,824 7,208

10,079

11,740

13,034

14,360

16,682 1.5 1.6 1.7 1.8

2.1 2.1 2.5

2.2 1.9 1.9

2.1

1.5 1.5 1.6 1.6 1.6 1.7

2.1

2.3 2.4 2.4 2.6

-4.0

-3.0

-2.0

-1.0

0.0

1.0

2.0

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Perc

enta

ge (%

)

RM

mill

ion

Year

PUBLIC (RM million) real RM2007 base PRIVATE Public as % GDP Private as % GDP

Source : MNHA (2007)

Ratio of Out-of-Pocket (OOP), Public & Private Expenditures

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0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

LowIncome

LowermiddleIncome

Malaysia UppermiddleIncome

HighIncome

GLOBAL

56.3 51.440.5

30.2

14.522.5

1.83.3

7.7

12.7

21.617.5

7.54.5

7.2

4.13.7

4.0

14.5

0.7

0.1

0.00.4

1.3

17.1

0.4 20.825.6

23.3

18.6 23.0

44.232.0 34.5 32.3 GenGov

RevenueSocialSecurityExternalResourcesOtherPrivatePrivatePooledPrivateOOP

MALAYSIA (2006)

Other Private (Employers)

Source: World Bank, 2005

Private Insurance

Total Expenditure on Health (TEH) as Percentage of GDP (2005)

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4.24.8

4.24.7

6.6

11.2

8.6

0.0

2.0

4.0

6.0

8.0

10.0

12.0

LowIncome LowermiddleIncome Malaysia Malaysia(2007) UppermiddleIncome HighIncome GLOBAL

TEHas%ofGDP,2005

Source : World Bank, 2005

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TRANSFORMING THE NATION

CARE FOR MALAYSIA

GovernmentTransforma>onProgramme

(GTP)• effec>vedeliveryofgovernmentservices

EconomicTransforma>on

Program(ETP)

• NewEconomicModel–ahighincome,inclusiveandsustainablena>on

Phase 1 Strengthening of

the current public system

TransformingtheNa>on

MALAYSIA People First, Performance Now

Phase 4 Full

reform funded through GT & SHI

Phase 3 PHC reform

funded through GT

Phase 2 Public Facility

autonomy funded through

GT

10th MP + 11th MP

Healthcare Transformation CARE FOR MALAYSIA

Aligning Our Health System To Our Country’s Aspirations

New Economic Model to be achieved through Economic Transformation Programme

(ETP) will propel Malaysia to a high income nation with inclusiveness and sustainability

8 Strategic reform initiatives: 1.  Re-energising the Private sector 2.  Developing quality workforce and reducing dependency on foreign

labour 3.  Creating a competitive domestic economy 4.  Strengthening of the public sector 5.  Transparent and market friendly affirmative action 6.  Building the knowledge base infrastructure 7.  Enhancing the sources of growth 8.  Ensuring sustainability of growth

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PROPOSED MODEL for MALAYSIA

1Care Concept

  1Care is the restructured integrated health system that is responsive and provides choice of quality health care, ensuring universal coverage for the health care needs of the population based on solidarity and equity

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Targets of 1Care

  Universal coverage   Integrated health care delivery system   Affordable & sustainable health care   Equitable (access & financing), efficient, higher

quality care & better health outcomes   Effective safety net   Responsive health care system   Client satisfaction   Personalised care   Reduce brain-drain 28

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Features of 1Care

  Streamlined MOH → focused on governance, stewardship and specific public health services, training and research

  Autonomous Malaysian Healthcare Delivery System (MHDS)- integrated public and private sector providers. People are registered with particular primary health care providers (PHCP) - gatekeeper to higher levels of care

  Publicly managed health fund - combination of general taxation and social health insurance (SHI), and tempered by minimal co-payments at point of seeking care

  Single payer system, the National Health Financing Authority (NHFA) – set-up on a not-for-profit basis under the MOH

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Features of 1Care

  Government commits to higher levels of spending for healthcare

  People commit to increased cost sharing through pooling of funds and cross-subsidy

POLICY MAKING

- Patient Safety -  Services -  Research -  TCM -  Human Resources Development -  Finance -  Infrastructure & Equipment - HTA -  Quality -  ICT

REGULATION & ENFORCEMENT

Legislation

MOH

MONITORING & EVALUATION

- HIC -  MNHA -  Surveillance -  H20 Quality -  TCM

PUBLIC HEALTH

- Disease Control

TRAINING

CHANGES TO THE CURRENT FUNCTIONS OF THE MINISTRY OF HEALTH (MOH) WITH THE PROPOSED RESTRUCTURING

- Drugs -  Quality -  HTA

- Food Safety & Quality

- Health Education

RESEARCH PERSONAL

CARE

Hospital Primary

- Professionals -  Allied Health

- Nursing

Enforcement

-Basic -Post-Basic

NHFA

Independent bodies -Drug Regulatory Authority (DRA) -Health Technology Assessment (HTA) -Medical Research Council (MRC) -Patience Safety Council -Medical Device Bureau -National Service Framework (NSF) (Quality) -National Health Promotion Board - Food Safety Authority - Others

Professional Bodies -MMC -MDC -Pharmacy Board - Others

Enforcement

MHDS

Regional Authority

Regional Authority

PHCT PHCT PHCT

Scope of Autonomy for Independent MOH-owned bodies

  Not-for-profit   Independent management board   Self accounting – manages own budget   Able to hire and fire   Flexibility to engage and remunerate staff

based on capability and performance   Accountable to MOH

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Primary Health Care

Primary Health Care   Thrust of health care services - strong focus on

promotive-preventive care & early intervention

  Primary Health Care Providers (PHCP): •  PHCP are independent contractors •  Family doctor & gatekeeper referral system

  Register entire population and PHCP

  Dispensing of drugs by pharmacies

  Financing through case-mix adjustments •  Payment by capitation with additional incentives

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•  PHCPs are led by Family Medicine Specialists (FMS) •  The FMS is registered with the MMC and the National

Specialist Register •  Secondary care specialist are not registered as PHCPs •  Conversion of GPs to FMS

•  Accreditation of facilities, credentialing and privileging of PHCP will be done

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Primary Health Care Provider

Hospital Services

  Autonomous hospital management

  Patients referred by PHCP

  Financing through casemix adjustments

•  Global budget for public hospitals •  Case-based payment for private hospitals

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Human Resource

•  Integration of public and private health care providers

•  Gaining of number & skills through integration

•  Harmonise / equalise remuneration for public and private

•  Pay for performance -  Incentives are being considered to promote performance -  Incentives for performance over benchmark, people who work in

remote areas •  In a multidisciplinary team, allied health personnel will

carry out more functions, such as: •  Preventive care by nurses •  Triaging, basic treatment e.g. T&S, STO, etc by nurses and

AMOs.

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FINANCING

Financing Arrangements

  Combination of financing mechanisms •  Social health insurance (SHI) + General taxation + minimal Co-payments

for a defined Benefits Package

•  Pooled as single fund to promote social solidarity and unity as per 1Malaysia concept

  Social Health Insurance contribution – mandatory •  SHI premium – community rated & calculated on sliding scale as

percentage of income

•  From employer, employee & government

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Financing Arrangements

  Government’s contribution (from general taxation) covers •  Public health & other MOH activities •  PHC portion of SHI for whole population

•  SHI premiums for registered poor, disabled, elderly (60 years & above), government pensioners & civil servants + 5 dependants

•  Higher spending by govt – 2.9% (In 2007 govt spending 2.1%)

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PHASES OF DEVELOPMENT

Steady State – 1Care for 1Malaysia

1Care: Full reform funded through GT & SHI

1Care: PHC reform funded through GT

1Care: Public Facility autonomy funded through GT

Phases of Health Sector Development

1Care: Strengthening of the current public system Phase 1

Phase 2

Phase 3

Phase 4

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GOVERNMENT

Flow of Healthcare Financing

Consolidated Revenue

MA N D A T O R Y

V O L U N T A R Y

National Health

Insurance

Savings, Out-of-pocket, Private Insurance

NHFA

HEALTHCARE PACKAGE

EXTRA COVERAGE / ADDED VALUE PACKAGES

RESTRUCTURED MOH HOSPITALS & CLINICS

PRIVATE SECTOR

REDUCE

GAPS

Employee Employer,

Self-employed, Foreign-workers

(Those who can afford)

Premium

PROPOSAL – ROADMAP

Pre-conditions for starting the phase to mitigate risks

▪  Definition of medical poor, and strong mechanisms for identifying them (e.g. e-Kasih)

▪  Ability to demonstrate better service levels and quality

▪  Ability to determine true cost of providing services (e.g. development of DRG, ACG)

▪  Increase in Class 1 and 2 beds to increase availability

▪  Improved collection mechanisms to reduce occurrence of bad debt

▪  Clear understanding of strengths and limitations of current exemption policy, and ways of mitigating

▪  Ability to demonstrate better service levels and quality

▪  Ability to determine true cost of providing services (e.g. Pharmacy Information System)

▪  Exemption for medical poor and special category individuals identified in Fees Act

▪  Exemption for medical poor and special category individuals identified in Fees Act

▪  Improve existing exemption provisions in Fees Act (e.g. children, mothers, welfare)

▪  Reimbursement for genuine Emergency cases

Safeguards

Proposal

▪  Introduce prescription charge for OP (flat rate)

▪  Introduce co-payment charges for inpatient treatment pegged to cost (e.g. 10% of cost)

▪  Suggest that move occurs by mid-2012

▪  Review outpatient fees to account for inflation

▪  Review inpatient ward charges to account for inflation

▪  Introduce charge for improper use of Emergency services

▪  Suggest that move occurs by Jan 2011

▪  Introduce co-payment charges for outpatients and inpatient

▪  Introduce co-payment charges for medication replacing flat rate

▪  Review current payment ceiling for 3rd class (currently RM 500)

Phased implementation with progression onwards dependant on the fulfillment of several pre-conditions

Horizon Two Jan 2013 – Dec 2014

Horizon One June 2010 – Dec 2012

Horizon Three 2015 onwards

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………Phase 4

  Full 1Care model

  Full integration of public and private health sector

including secondary and tertiary care

  Funded through GT and SHI

  NHFA - manages overall health care financing in

close collaboration with MOH and MHDS.

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  Sensitive nature of topic - social service affects everyone   Involves many stakeholders – effective strategic

communication required   Scale of change and restructuring requires considerable

financial investment and commitment   Realistic time frame & phased implementation

- Outline Perspective Plan for the Health Sector • Beginning with transformation theme -10MP

  Many phases proposed, each overlapping on the other - Building blocks to lay foundation and pave the way

Caution & Concerns

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IMPLICATIONS

Benefits to the Nation…1

1. Strengthen National Unity -  1Malaysia – Social solidarity through SHI contribution

addressing marginalised segments of the population -  1Care – National health care programme emphasising

the ethical delivery of health care

2. Stimulate Health Care Market - Increase health care spending in line with upper

middle income status -  Enhance public/private intergration –Increasing

productivity and system responsiveness

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Benefits to the Nation…2

3. Capitalise on liberalisation and global health care market

- Attract highly skilled health personnel - Support health care travel

4. Reduce dependence on government -  Decrease leakage of government spending -  Those who can afford will contribute through SHI -  Cross subsidy by the rich to poor, healthy to sick,

economically productive to dependants (1Malaysia) - Enhance corporate social responsibility through

employer contribution (1Malaysia) 48

Benefits to the Nation…3

5. Ensure social safety nets for lower & middle income -  Better financial risk management - Reduce OOP at point

of seeking care by prepayment of services -  Address equity & access of care - Coverage of poor,

disabled & elderly through general taxation -  Lower insurance premium with wider benefits

6. Contain rapid growth in health care cost - Address market failures of health care system - promote

greater efficiency e.g. reduces duplication, increase competition

-  More public management of health care financing – better control of health care inflation 49

Benefits to the People

  Access to both public & private providers   Reduced payment at the point of seeking

care   Care nearer to home   Increased quality of care & client satisfaction   Personalised care   Access for vulnerable group   Better health outcome   Higher work productivity

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Benefits to Employer

  Relieve burden to reimburse worker or give loan for medical spending

  Relieve burden to cover non-work and work related illnesses (beyond SOCSO)

  Pay low contributions   Reduce administration to process medical benefits   Avoid systems in which unnecessary care lead to higher

expenditure e.g. PHI, MCO & Panel doctors   Healthier workforce and higher productivity

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Benefits to Health Care Providers

  Bridge the gap between remuneration and work load among health workers in the public and private sectors.

  Reduce brain-drain   Re-address distribution of health staffs through

the provision of specific incentives.   Ensure appropriate competency through training

and credentialling   Defined standards of care

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Status Quo Strengthening Autonomy PHC

Reform

A journey of a thousand miles begins with a single step. Lao-tzu

Chinese Philosopher (604 BC - 531 BC)

Full 1Care

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VISION 2020 States that "by the year 2020, Malaysia is to be a united nation

with a confident Malaysian Society infused by strong moral and ethical values, living in a society that is democratic, liberal and tolerant, caring, economically just and equitable, progressive and prosperous, and in full possession of an economy that is competitive, dynamic, robust and resilient".

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NATIONAL MISSION THRUSTS   THRUST 1 :To move the economy up the value chain   THRUST 2 :To raise the capacity for knowledge and

innovation and nurture ‘first class mentality’

  THRUST 3 : To address persistent socio-economic inequalities constructively and productively

  THRUST 4 : To improve the standard and sustainability of quality of life

  THRUST 5 :To strengthen the institutional and implementation capacity

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10MP 6 STRATEGIC DIRECTIONS

HIGH INCOME ADVANCED ECONOMY

HS 6 Government

As an Effective Facilitator

HS3 Creative & Innovative

Human Capital With 21st Century

Skill

HS5 Quality Of Life

Of An Advanced Nation

HS4 Inclusiveness

In Bridging Development

Gap

HS2 Productivity &

Innovation Through K-Economy

HS 1 Competitive

Private Sector as Engine of Growth

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10MP STRATEGIES FOR KRA 2 : Ensure Access to Quality Healthcare & Promote Healthy Lifestyle

HIGH INCOME ADVANCED ECONOMY

HS5 Quality Of Life Of An

Advanced Nation

OUTCOME (Ensure provision of and Increase accessibility to Quality health care and

Public recreational and Sports facilities to support Active healthy lifestyle)

Establish a comprehensive healthcare system & recreational infrastructure

Encourage health awareness & healthy lifestyle activities

Empower the community to plan or conduct individual wellness programme (responsible for own health)

Transform the health sector to increase the efficiency & effectiveness of the delivery system

KRA 2

STRATEGY 1 STRATEGY 2 STRATEGY 3 STRATEGY 4

Ensure Access To Quality Healthcare & Promote Healthy Lifestyle

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SUMMARY Transformation Agenda

VISION 2020

NATIONAL MISSION THRUST 2006-2020

THRUST 1 To move the

economy up the value chain

THRUST 2 To raise the capacity

for knowledge & innovation & nurture ‘first class mentality’

THRUST 3 To address persistent

socio-economic inequalities

constructively & productively

THRUST 4 To improve the

standard & sustainability of quality of life

THRUST 5 To strengthen the

institutional & implementation capacity

Quality of Life of An Advanced Nation

Ensure provision of & Increase accessibility to Quality health care & Public Recreational & Sports facilities to support Active healthy

lifestyle

Strategy 1 -- comprehensive

healthcare & recreation

Strategy 2 -- health awareness &

Healthy lifestyle

Strategy 3 -- Empowering the Community

towards self care

Strategy 4 -- Health Sector Transformation

(Universal Access)

10MPSTRATEGIC DIRECTION 5 (HS5)

10MP OUTCOME FOR HS5

10MP STRATEGIES FOR HS5

Ensure access to quality Healthcare & promote

Healthy lifestyle 10MP KRA 2 FOR HS5

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DEVELOPMENT BUDGET 9MP BUDGET 230 B

10MP BUDGET 165 B Development Expenditure 15 B PFI Facilitation Fund 50 B PFI

Ceiling for 2011-2012 (2 year rolling plan) (RM 75 B for the whole country)

NKRA projects – 21B Continued 9MP Projects – 40B New projects & Private Facilitation Fund – 14B

TOTAL 230 B

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CONCLUSION •  Challenge is big ahead of us

•  Infrastructure development has to be ready for the new era

• Sharing of ideas would prepare us for the next step in Rolling Plan 2 in RMK-10 & RMK-11 before becoming a developed nation by 2020

TERIMA KASIH ATAS PERHATIAN ANDA