TOWARDS ACHIEVING BETTER HEALTH

MALAYSIAN HEALTHCARE SYSTEM

CARE FOR

MALAYSIA

Dr. Abd. Rahim bin Mohamad Planning and Development

Putrajaya 28 September 2010

Welcome Selamat Datang, Salam Eidil Fitri

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
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MINISTRY OF HEALTH
Other Govt Agency University, MOE, Youth & Sports

International WHO, UNICEF, UNDP

MOH

Private Sector GPs, Private Hospitals, TCM, NGO MMA, PPIM,MOPI,

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Consumers Elderly, Youth, Children

MINISTRY OF HEALTH
Technical Ministry Punctuality Fast Services Evidenced based Caring Professionalism Teamwork

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

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

PROBLEM STATEMENTS

Issues raised concerning public medical services

Issues raised concerning private sector

Long waiting time Postponed cases Overworked staff in 3rd class wards impersonal.. Lack of choice Inadequate amenities

Exorbitant charges Increasing private insurance premium Appropriateness of care vs. overservicing

PROBLEM STATEMENTS

National Health Account Study 2006

Out-of-pocket (OOP) spending in Malaysia is high (40% of THE) OOP spending in developed countries is low
RM 9805 million
<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)

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

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Current Functions of MOH

Within the dual health care system, MOH is Funder, Provider and Regulator

Health Policies & Planning Public Health Activities

Primary Care Services

Communicable Disease Non-communicable Disease Personal care Public Health Pharmacy Technology Medical Devices
Quality Assurance Health Technology Assessment Patient Safety Guidelines and Standards

Regulation & Enforcement

Out-patient services Maternal & Child Health Health Education Home Visits & School Health In-patient services Specialist care

Secondary & Tertiary Services

Monitoring & Evaluation

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

Training Research & Development

Basic Health Services

Hospitals Special Medical Institutions(SMI) Special Institutions Non MOH Hosp Private hospitals Private maternity home Private Nursing Home

Number 130 6

Beds 33,083 4,974

6 (PDN,PHLab) 8 3,523 209 12,216 21 102 12 273

Health Facts 2009

Basic Health Services

Health Clinic(KK) Community Clinic(KD) Maternal &Child Clinic Mobile Health Clinic KKM Dental Clinic KKM Mobile Dental Clinic Private GPs Private Dental Clinics

Number 808 1,920 90 196 1,724 (2,952 dental chairs) 560 (1,392 dental chairs) 6,307 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)

11% 38% 41% 78% 74% 55% 45%

Source: Health Informatics Center (HIC),MOH

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

Source : MNHA (2007)
18,000

2.5 2.1 2.1 2.1 1.6 1.7 1.6 1.5 1.7 1.6 1.8 1.6

2.3 2.2

2.4

2.4

2.6 2.1
2.0

16,000

1.5 1.5

1.9

1.9
14,360

16,682

1.0 13,546
Percentage (%)

14,000

13,034

RM million

12,000

12,067 11,558
11,740

0.0 11,542 10,271 -1.0

10,000 8,727 8,000 6,351

6,571 5,970 5,538

9,083

10,079

-2.0 7,320
7,208 6,824

6,000

5,616
5,658

5,806

-3.0

4,000

-4.0

1997

1998

1999

2000

2001
Year

2002

2003

2004

2005

2006

2007

PUBLIC (RM million) real RM2007 base

PRIVATE

Public as % GDP

Private as % GDP

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

100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Low Income Lower middle Income
MALAYSIA Malaysia (2006)

18.6 1.3 14.5 7.5 1.8

23.0
44.2

32.0

34.5

32.3

17.1 0.7 4.5 3.3 0.4

7.2 7.7

20.8 0.1 4.1 12.7

25.6 0.0 3.7 21.6

23.3 0.4 4.0 17.5 22.5

56.3

51.4

40.5

30.2 14.5 Upper middle Income High Income

GenGov Revenue Social Security External Resources Other Other Private Private (Employers) Private Private Pooled Insurance PrivateOOP

GLOBAL
21 Source: World Bank, 2005

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

TEHas%ofGDP,2005
12.0

11.2

10.0

8.6
8.0

6.6
6.0

4.2
4.0

4.8

4.2

4.7

2.0

0.0

LowIncome

LowermiddleIncome

Malaysia

Malaysia(2007) UppermiddleIncome

HighIncome

GLOBAL22

Source : World Bank, 2005

TRANSFORMING THE NATION

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TransformingtheNa>on MALAYSIA
People First, Performance Now Healthcare Transformation CARE FOR MALAYSIA MALAYSIA
Phase 2
Public Facility autonomy funded through GT

eec>vedeliveryof
governmentservices

Government Transforma>on Programme (GTP)

NewEconomicModel ahighincome, inclusiveand sustainablena>on

Economic Transforma>on Program CARE FOR (ETP)

Phase 1
Strengthening of the current public system

Phase 3
PHC reform funded through GT

Phase 4
Full reform funded through GT & SHI

10th MP

11th MP

Aligning Our Health System To Our Countrys 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. 2.

3. 4. 5. 6. 7. 8.

Re-energising the Private sector Developing quality workforce and reducing dependency on foreign labour Creating a competitive domestic economy Strengthening of the public sector Transparent and market friendly affirmative action Building the knowledge base infrastructure Enhancing the sources of growth 25 Ensuring sustainability of growth

PROPOSED MODEL for MALAYSIA

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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
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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

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CHANGES TO THE CURRENT FUNCTIONS OF THE MINISTRY OF HEALTH (MOH) WITH THE PROPOSED RESTRUCTURING
Professional Bodies -MMC -MDC -Pharmacy Board - Others

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

NHFA

MOH

PUBLIC HEALTH -Disease Control

-Food Safety & Quality -Health Education

MONITORING & EVALUATION

POLICY MAKING

REGULATION & ENFORCEMENT

TRAINING

RESEARCH

PERSONAL MHDS CARE

-HIC - MNHA - Surveillance - H20 Quality - TCM -Drugs - Quality - HTA

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

-Basic -Post-Basic Enforcement

Legislation Regional
Authority

Primary

Hospital
Regional Authority

-Professionals - Allied Health -Nursing

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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Primary Health Care Provider

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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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.

FINANCING

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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

Governments 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

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Phases of Health Sector 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
1 Phase 4

Phase 3 Phase 2

1Care: Strengthening of the current public system Phase

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Flow of Healthcare Financing

Consolidated Revenue

GOVERNMENT

Employee Employer, Self-employed, Foreignworkers (Those who can afford)

MA N D A T O R Y

Premium

National Health Insurance

NHFA

HEALTHCARE PACKAGE

RESTRUCTURED MOH HOSPITALS & CLINICS

R E D U C E G A P S
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V O L U N T A R Y

Savings, Out-of-pocket, Private Insurance

EXTRA COVERAGE / ADDED VALUE PACKAGES

PRIVATE SECTOR

PROPOSAL ROADMAP Phased implementation with progression onwards dependant on the fulfillment of several pre-conditions
Horizon One June 2010 Dec 2012 Horizon Two Jan 2013 Dec 2014 Horizon Three 2015 onwards

Review outpatient fees to account

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

Safeguards

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 Improve existing exemption provisions in Fees Act (e.g. children, mothers, welfare) Reimbursement for genuine Emergency cases

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)

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

Preconditions for starting the phase to mitigate risks

Improved collection mechanisms

to reduce occurrence of bad debt Clear understanding of strengths and limitations of current exemption policy, and ways of mitigating

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

Ability to demonstrate
better service levels and quality Ability to determine true cost of providing services (e.g. Pharmacy Information System) 43

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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Caution & Concerns

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

IMPLICATIONS

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Benefits to the Nation1

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 Nation2

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)
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Benefits to the Nation3

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

Chinese Philosopher (604 BC - 531 BC)

Full 1Care

Status Quo

Strengthening

Autonomy

PHC Reform

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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

HS 1
Competitive Private Sector as Engine of Growth

HS2
Productivity & Innovation Through K-Economy

HS 6
Government As an Effective Facilitator

HIGH INCOME ADVANCED ECONOMY

HS3
Creative & Innovative Human Capital With 21st Century Skill

HS5
Quality Of Life Of An Advanced Nation

HS4
Inclusiveness In Bridging Development Gap

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10MP STRATEGIES FOR KRA 2 :

Ensure Access to Quality Healthcare & Promote Healthy Lifestyle

HS5 Quality Of Life Of An Advanced Nation

HIGH INCOME ADVANCED ECONOMY

KRA 2 Ensure Access To Quality Healthcare & Promote Healthy Lifestyle

OUTCOME (Ensure provision of and Increase accessibility to Quality health care and Public recreational and Sports facilities to support Active healthy lifestyle) STRATEGY 1
Establish a comprehensive healthcare system & recreational infrastructure

STRATEGY 2
Encourage health awareness & healthy lifestyle activities

STRATEGY 3
Empower the community to plan or conduct individual wellness programme (responsible for own health)

STRATEGY 4
Transform the health sector to increase the efficiency & effectiveness of the delivery system

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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

To address persistent socio-economic inequalities constructively & productively

THRUST 3

THRUST 4
To improve the standard & sustainability of quality of life

THRUST 5
To strengthen the institutional & implementation capacity

10MPSTRATEGIC DIRECTION 5 (HS5)

Quality of Life of An Advanced Nation Ensure access to quality Healthcare & promote Healthy lifestyle

10MP KRA 2 FOR HS5 10MP OUTCOME FOR HS5

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

10MP STRATEGIES FOR HS5

Strategy 1 -- comprehensive healthcare & recreation Strategy 2 -- health awareness & Healthy lifestyle Strategy 3 -- Empowering the Community towards self care

Strategy 4 -- Health Sector 58 Transformation 58 (Universal Access)

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
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TERIMA KASIH ATAS PERHATIAN ANDA