Implicit & Explicit Benefit     Implicit & Explicit Benefit      Package: Pros & Cons      Package: Pros & Cons           ...
Malaysian Health System                                                         3Life Expectancy at Birth                 ...
Selected Vital Statistics       80.0                        Malaysia 1957‐2006                        M l i 1957 2006     ...
Poverty Impact of Health Expenditures                                                                                     ...
1Malaysia clinics and Community clinics                                                                                   ...
SECONDARY / TERTIARY CAREFor the regionali ed services, FOCUS is given to 6For the regionalized services, FOCUS is given t...
Health System Sustainability                Public Private Expenditure on Health                      1997 – 2009 (2011 va...
Components of 1Care for 1Malaysia                         1. Service Delivery Reforms                     • Increase quali...
SCOPE of BENEFIT PACKAGE  (BP)• BP ‐ in low‐income country consists of a limited list   of services or interventions while...
Characteristics of Implicit BPi.     Rationing without a (single) defined rationing planii. Implicit rationing is implemen...
IMPLICIT ‐ Pros• Possibility of securing and maintaining the ideal/idea of a health care system that will in all instances...
IMPLICIT ‐ Cons   • This approach may not be able to achieve an      efficient allocation of resources, since health      ...
Explicit ‐ Pros                                    Waste fewer                                    resources,              ...
EXPLICIT ‐ Pros   In Italy, a clear definition of the benefits provided    In Italy a clear definition of the benefits pro...
EXPLICIT ‐ Cons    • New Policy Instruments and Technical solution       –   Clarity about objectives, outcomes           ...
EXPLICIT – Cons• Potential for distress for frontline providers    ote t a o d st ess o o t e p o de s  caused through rat...
References•   Del Vecchio M (1997) Guaranteed entitlement to health care: an Italian point of view. In: Lenaghan    J (ed)...
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2012 speaker-ps42-rozita halina tun hussein

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This is MOH Deputy Director Dr Rozita Halina Tun Hussein's presentation at the Prince Mahidol Award Conference, January 2012.

She is speaking on Malaysia's experience in formulating a health care rationing method.

Healthcare rationing is a well-known fact of Insurance based healthcare systems. But the government insists that Malaysians will get all the healthcare they need for free.

This is a blatant lie!

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2012 speaker-ps42-rozita halina tun hussein

  1. 1. Implicit & Explicit Benefit  Implicit & Explicit Benefit Package: Pros & Cons Package: Pros & Cons Dr Rozita Halina Tun Hussein Unit for National Health Financing Unit for National Health Financing Planning and Development Division Ministry of Health, Malaysia rozitahalina@moh.gov.my it h li @ h 1 Overview• The context of Malaysia• Definitions and Scope of Benefit Package (BP) Definitions and Scope of Benefit Package (BP)• Implicit BP Pros & Cons• Explicit BP Pros & Cons• Conclusion• ReferencesAcknowledgement  Dr MunizamAcknowledgement – Dr Munizam Abd Majid, Dr Mastura Majid, Dr Mastura Mohd Tahir and Dr Zakiah Zainuddin 2
  2. 2. Malaysian Health System 3Life Expectancy at Birth Female, 2009  , 76.5 Male,2009  71.7 4 Source: Source: Department of Statistics, Malaysia
  3. 3. Selected Vital Statistics  80.0 Malaysia 1957‐2006 M l i 1957 2006 70.0 IMR 60.0 50.0 40.0 NMR 30.0 20.0 CDR 10.0 TMR 0.0 1957 1960 1970 1980 1990 1995 1999 2001 2002 2003 2004 2005 2006 Source : Department of Statistics, Malaysia Targeting of Public SpendingSource: Rozita Halina, 2000  6
  4. 4. Poverty Impact of Health Expenditures Pre and post OOP payment income, Malaysia 1999 200 180 ultiples of $1 PL L 160 140 sumption as mu 120 100per capita cons 80 60 40 20 0 0.00 0.04 0.09 0.12 0.16 0.19 0.23 0.26 0.29 0.32 0.35 0.38 0.41 0.44 0.47 0.50 0.52 0.55 0.58 0.60 0.63 0.65 0.68 0.70 0.73 0.75 0.77 0.79 0.81 0.83 0.85 0.87 0.89 0.91 0.93 0.94 0.96 0.98 0.99 cum. proportion of persons in ascending order of consumptionSource Ng CW - Equitap $1.08 PL Pre OOP consumption Post OOP consumption 7 Primary Health Care Comprehensive Deconcentrated Comprehensive Deconcentrated System Mother and Child Family Planning Outpatient Home Visits Dental 2000 1980 Pharmacy Mother and Child Lab Child w Special Needs 1960 Family Planning Outpatient Reproductive Clinic Elderly Adolescent Mother and Child Home Visits Geriatric Dental Emergency Family Planning Health informatics Outpatient O i Pharmacy Occupational Health Clinic Lab Diabetic Clinic 8
  5. 5. 1Malaysia clinics and Community clinics 9 Health Services at District Level DISTRICT  HEALTH OFFICE No. : 139*OUTREACH SERVICES FLYING DOCTORS HEALTH CLINIC No. : 807* Coverage: 20,000  pop COMMUNITY HEALTH CLINICS / KLINIK  DESA • No 2158* No. : 2158* • Coverage: 4,000 population MOBILE TEAM 10 * DEC 2006 * Dec 2006
  6. 6. SECONDARY / TERTIARY CAREFor the regionali ed services, FOCUS is given to 6For the regionalized services, FOCUS is given to 26  specialty / subspecialty services:1. RESPIRATORY MED. 10.       NEUROLOGY 20. UROLOGY2. INFECT. DISEASES 11.     ENDOCRINOLOGY 21. PAEDIATRIC SURGERY3. RHEUMATOLOGY 12.     ONCOLOGY 22. PLASTIC SURGERY4. HEPATOLOGY 13. UPPER GI SURG. 23. CARDIAC PERFUSION 5.5 PALLIATIVE  PALLIATIVE 14. 14 COLORECTAL SURG. COLORECTAL SURG ANAES. ANAES MEDICINE 15. HEPATOBILIARY SURG. 24. NUCLEAR MEDICINE6. HAEMATOLOGY 16. BREAST/ ENDOC SURG. 25. REHABILITATION  REHABILITATION7. GASTROENTERO. 17. VASCULAR SURGERY MEDICINE8. CARDIOLOGY 18. NEUROSURGERY 26. FORENSIC MEDICINE9. GERIATRIC 19. CARDIOTHORACIC  SURGERY Other sub-specialisations and areas of competence continue to be developed. 11 CENTRES OF EXCELLENCE • Collaboration with  US
  7. 7. Health System Sustainability  Public Private Expenditure on Health  1997 – 2009 (2011 value) 1997 2009 (2011 l ) 25.00 5.0 5.00 4.4 4.50 4.2 4.2 4.1 4.1 3.8 3.9 20.00 3.7 19.1 4.00 17.3 3.3 16.3 3.50 3.2 16.1 3.1 15.2 2.9 14.6 15.00 3.00 12.9 12 9 15.9 12.0 14.8 2.50 11.4 14.2 13.4 10.00 9.5 12.5 2.00 8.6 11.6 10.6 10 6 7.8 7.7 1.50 9.1 8.2 5.00 7.6 1.00 6.1 6.8 6.0 0.50 0.00 0.00 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Public Exp (RMbill in 2011  RM value) Private Exp (RMbill in 2011  RM value) THE as % GDP 13 Source – MNHA Three Dimensions to Consider When  Improving Universal Coverage  Improving Universal CoverageSource : Health System Financing, WHO Report, 2010 14
  8. 8. Components of 1Care for 1Malaysia  1. Service Delivery Reforms • Increase quality of care • Public & Private healthcare delivery • Family doctor for each individual Family doctor for each individual • Gatekeeper to higher level • Defined benefit package3. Financing Reforms 2. Organisational Reforms • Mixed financing • Public Sector autonomyy SHI (by NHFA) • Streamlining MOH General taxation  Stewardship  • Purchaser Provider Split Governance • Relevant PPM l Public health services • Incentives Research • Pay for Performance Training 15DEFINITION of BENEFIT PACKAGE• BP refers to ‘the totality of services, activities, and  P refers to the totality of services, activities, and goods covered by PUBLICLY FUNDED  y/ y statutory/mandatory insurance schemes’ – EU Health  BASKET project• Essential BP aims to concentrate scarce resources  o te e t o s on interventions which provide the best value for  c p o de t e best a ue fo money.  – often expected to achieve multiple goals: often expected to achieve multiple goals: improved efficiency; equity; political empowerment,  accountability, and altogether more effective care.  (WHO 2008) 16
  9. 9. SCOPE of BENEFIT PACKAGE  (BP)• BP ‐ in low‐income country consists of a limited list  of services or interventions while, in richer  countries packages are often described according  to what they exclude. • Essential Benefits package (BP) will become the  p g ( ) standard for health coverage and will be used as  g the basis for establishing the different benefit levels  of plans that will be offered … the minimum that all  new health plans have to cover (Families USA Sept 2009  about Health Reform Legislation – benefits in different health  plans in the health insurance exchange) 17 WHAT IS IMPLICIT BP? • Broadly defined general categories of care, and  then leave the more specific decisions to health  then leave the more specific decisions to health professionals and/or politicians.  • Utilised in  – New Zealand prior to health reforms in the early New Zealand prior to health reforms in the early  1990s (Wong & Bitrán 1999) – Primary Healthcare Services in Britain (Clarkeburn 1998) – Malaysia’s public health care sector Malaysia s public health care sector 18
  10. 10. Characteristics of Implicit BPi. Rationing without a (single) defined rationing planii. Implicit rationing is implemented by using one or more  subtle ways to rationiii. In an implicit rationing model, no one person or  institution takes responsibility for making resource  allocation choices in health care = invisible rationing.  ll ti h i i h lth i i ibl ti iiv. People directly affected or making these implicit rationing  choices do not know which choices have actually been  h d k h h h h ll b taken or on what grounds. v. Inclusions of the health service are often publicly known,  while exclusions are performed implicitly.vi. Implicit rationing choices are localized. Health care  providers = role as rationing agents.                 (Clarkeburn 1998) 19 IMPLICIT ‐ Pros • Increase population coverage by limiting service  coverage (Ham & Coulter 2001). • Allows flexibility (Wong & Bitrán 1999) Allows flexibility (Wong & 1999). • May actually be a better way of dealing with  difficult and complex issues. (Hunter 1995) difficult and complex issues (H t 1995) • Minimize political resistance ‐ No explicit  exclusions to serve as a focal point for opposition  (Wong & Bitrán 1999). • Politicians are shielded/praised from the impact  of decisions about who not to treat and who to  treat (Hunter 1995). 20
  11. 11. IMPLICIT ‐ Pros• Possibility of securing and maintaining the ideal/idea of a health care system that will in all instances do the most for every single individual (Clarkeburn 1998)• At the point of service maybe more sensitive to  – the complexity of medical decisions and  p y – the needs and personal and cultural preferences of  p patients      (Mechanic 1995) ( )In Malaysia, health care providers are the key I M l i h lth id th kdecision‐makers about demand for health care 21 IMPLICIT ‐ Cons • Places a great responsibility on health care  l ibili h lh providers  • Given only minimal guidelines  • May sacrifice their professional integrity May sacrifice their professional integrity  • Uncertainty on actual services covered • chance of patients receiving most appropriate  health care can be influenced by their luck in  finding the right healthcare provider and/or by / their place of residence, as local health  authorities may have made differing decisions on  a thorities ma ha e made differing decisions on the services provided  (Clarkeburn 1998) 22
  12. 12. IMPLICIT ‐ Cons • This approach may not be able to achieve an  efficient allocation of resources, since health  planners, clinicians and politicians may have  conflicts of interest and differing priorities in  conflicts of interest and differing priorities in determining which services to provide • Tool for political mileage lf l l l • Own incentives may not closely match with Own incentives may not closely match with  those of society as a whole (Wong & Bitrán 1999). 23 WHAT IS EXPLICIT BP?• Identifying and using standard specific criteria(s) to  identify services which should receive priority d f h h h ld – the identification of community needs and preferences – the criteria of cost effectiveness and/or efficiency – criteria that a health problem involves a large number of criteria that a health problem involves a large number of  people, services are available and effective, and quantified  g targets can be set• A positive list of included interventions or a negative list  of excluded interventions of excluded interventions• When governments decide to purchase health care from  private or public providers, BPs must necessarily be  explicit 24
  13. 13. Explicit ‐ Pros Waste fewer resources, Financial More protection and technical Greater beneficiary efficiency accountability satisfaction ti f ti Better legitimacy Citizen of rationing empowerment - decisions, fair, right to demand democratic Get more What can healthfor your money, explicit BPs li it BP More potentially equity Value for money y achieve? 25 (Bitran& Giedion, 2009) EXPLICIT ‐ Pros In Chile: • Quality: Each health problem has a specific  p protocol developed in a process of reviewing  p p g clinical guidelines and adjusting to available  human and technical resources  designed to  human and technical resources – designed to be as high quality as is realistic in Chilean  conditions. • Timeliness: Protocols have maximum times  for diagnosis, treatment and follow‐up. If  for diagnosis treatment and follow up If provider fails to meet the timing, it is required  to pay an alternative provider. to pay an alternative provider (Bossert 2009) 26
  14. 14. EXPLICIT ‐ Pros In Italy, a clear definition of the benefits provided  In Italy a clear definition of the benefits provided by the statutory system maybe beneficial for  several reasons:  several reasons 1. it can contribute to a better allocation of  resources, (allocative efficiency) 2. helps reassure beneficiaries about their rights  2 helps reassure beneficiaries about their rights and responsibilities, and 3. facilitate the development of supplementary  insurance  (Del Vecchio M 1997 & Torbica & Fattore 2005) 27 EXPLICIT – Cons• May result in more resources being allocated to the health  g care budget      (Ham & Coulter 2001) ( ) – What is the unmet need, what further investments are needed,  actual availability of services (addressing equity of access)• Likely to focus conflict and dissatisfaction,  politically  destabilizing.  (Mechanic 1995).  In the USA, ‘attempts to ration  health care explicitly are  political dynamite health care explicitly are ‘political dynamite’ ((Ham & Coulter 2001)) & l• Explicit priority setting is a continuing process which is not  amenable to  once and for all solutions Have put in place amenable to ‘once and for all’ solutions. Have put in place  mechanisms to ensure that the issues involved are kept under  CONTINUOUS REVIEW (Ham 1997)• Criteria approach ‐ may be difficult for the population to  agree on what criteria to use, difficulties in measurement  (Wong & Bitrán 1999). (Wong & Bitrán 1999) 28
  15. 15. EXPLICIT ‐ Cons • New Policy Instruments and Technical solution – Clarity about objectives, outcomes Clarity about objectives outcomes – Good information/ data/ health technology assessment – Evidence base – Ability and methodology to measure performance • Capacity and Knowledge of policy maker and other  p y g p y stakeholders • Effective “vehicles” for BP implementation  Effective  vehicles for BP implementation – Clinical or quality assurance protocols, including for referrals. – Contracting providers to provide the essential package. – The regulation and accreditation of individual facilities. – Supervision. – Assigning inputs t A i i i t to meet the needs of the BP – i f t t t th d f th BP infrastructure  plans, essential equipment lists etc. (Ham & Coulter, 2001) 29 Malaysia – Implicit to Explicit BP• Criteria – Disease burden, waiting times to tx• Methodology – representation, voice, data, source• Financing – who bears the cost Fi i h b h• Understanding – services to be provided and not g p• Criteria to document what is provided now –B dC Broad Categories Vs Specific Service/Product/Procedure i V S ifi S i /P d /P d – Technology (Minimum threshold), CPG, Clinical pathway – Indications, Population , Provider, Referral threshold – Current waiting times (assessment of unmet need) Current waiting times (assessment of unmet need) – Cost and cost effectiveness, source of funding, co‐pay 30
  16. 16. EXPLICIT – Cons• Potential for distress for frontline providers  ote t a o d st ess o o t e p o de s caused through rationing openly • Wh th Whether explicitness is always the best  li it i l th b t approach at the consultation level??• Professionals need further training and support  to deal with the stressful nature of making  to deal with the stressful nature of making rationing decisions openly.  (Smith, Coast & Donovan, 2010)• Implementing an BP is not just a technical l h l exercise – political and institutional processes  need to be engaged 31 Conclusion • Many comparison of merits and difficulties  p p p g with implicit and explicit benefit packages. • Moot point with purchaser provider split • R Recently, the issue now is how best to  l h i i h b develop a more explicit BP • Globally, a mixture of implicit and explicit BP – how to strike the balance. how to strike the balance 32
  17. 17. References• Del Vecchio M (1997) Guaranteed entitlement to health care: an Italian point of view. In: Lenaghan J (ed) Hard choices in health care. BMJ Books:London• Ham, C. Coulter, A. 2001. Explicit and implicit rationing: taking responsibility and avoiding blame for  health care choices. Journal of Health Services Research & Policy Vol 6 No 3, 2001: 163 169 health care choices Journal of Health Services Research & Policy Vol 6 No 3 2001: 163–169• Wong, H. Bitrán, R. 1999. Designing A Benefits Package. World Bank Institute.• Hunter, D.J.  1995. Rationing health care: the political perspective. Br Med Bull (1995) 51 (4): 876‐ 884.• Mechanic, D. 1995. Dilemmas in rationing health care services: the case for implicit rationing. BMJ  h l h lh h f l 1995:310:1655‐9• Torbica, A. Fattore, G. 2005. The “Essential Levels of Care” in Italy: when being explicit serves the  devolution of powers. Eur J Health Econom 2005 ∙ [Suppl 1] 6:46–52• Guerrero, R. Ornelas, H. A. Knaul, F. M. 2010. The world health report. Health system financing.  Technical Brief Series ‐ Brief No 13. Breadth and depth of benefit packages: lessons from Latin  America. World Health Organization.• Smith, A. O. Coast, J. Donovan, J. 2010. The desirability of being open about health care rationing  decisions: findings from a qualitative study of patients and clinical professionals. Journal of Health  d ii fi di f lit ti t d f ti t d li i l f i l J l f H lth Services Research & Policy Vol 15 No 1, 2010: 14–20• Sabik, L. M. Lie, K. R. 2008. Priority setting in health care: Lessons from the experiences of eight  countries. International Journal for Equity in Health 2008, 7:4• Alexander GC, Werner RM, Ubel PA: The Costs of Denying Scarcity. Archives of Internal Medicine  Alexander GC Werner RM Ubel PA: The Costs of Denying Scarcity Archives of Internal Medicine 2004, 164:593‐596.• Fleck LM: Rationing: Dont Give Up. Hastings Center Report 2002, 32:35‐36.• Fleck LM: Just Caring: Health Reform and Health Care Rationing. Journal of Medicine and  Philosophy 1994, 19:435 443. Philosophy 1994 19:435‐443• Ham, C. 1997. Priority setting in health care: learning from international experience. Health Policy  42 (1997) 49–66 33 Thank you Th k y 34

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