1 Care for Malaysia
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1 Care for Malaysia

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  • 1. 1Care for 1Malaysia:RESTRUCTURING THE MALAYSIAN HEALTH SYSTEM Presented at the 10th Malaysia Health Plan Conference by Dato’ Dr Maimunah bt A Hamid Deputy Director General of Health (Research and Technical Support) 2nd February 2010 1
  • 2. Presentation Outline• Current Health System & Challenges• Proposed Model for Malaysia – Delivery system & Governance • Primary Health Care • Secondary Care • Human Resource Development – Financing• Implications 2
  • 3. CURRENT HEALTH SYSTEM & CHALLENGES 3
  • 4. Overview of Current Malaysian Health System 4
  • 5. Access to Health Providers in Malaysia MOH Other agencies & Private sector By passingSECONDARY/TERTIARY University Hospitals CARE Hospitals with Private Hospitals Subspecialty Hospitals with Specialists Others Medical Corps Hospitals without Specialists Orang Asli Facilities GPsPRIMARY HEALTH Health Clinics/Centres 1 : 20,000 population CARE Rural/Community Clinics 1 : 4,000 population Estate
  • 6. Public & Private Sector Resources and Workload (2008) 11% Health clinics (with doctors) 802 6371 38% Outpatient visits (m) 38.4 62.65 41% No. of Hospitals 143 209 78% Hospital Beds 41249 11689 74% Admissions 2199310 754378 55% Doctors (excl. Houseman) 12081 10006 45%Health Expenditure (RM billion) (2007) 13.54 16.68 Public Private 0% 20% 40% 60% 80% 100% 10 Source: Health Informatics Center (HIC),MOH 6
  • 7. Current Functions of MOHWithin the dual health care system,MOH is Funder, Provider and Regulator• Health Policies & Planning • Primary Care Services – Out-patient services• Regulation & Enforcement – Maternal & Child Health – Personal care – Health Education – Public Health – Home Visits & School Health – Pharmacy • Secondary & Tertiary Services – Technology – In-patient services – Medical Devices – Specialist care• Monitoring & Evaluation • Pharmaceutical Services – Quality Assurance • Oral Health Services – Health Technology Assessment – Patient Safety • Imaging and Diagnostics – Guidelines and Standards • Laboratory Services• Training • Telehealth & Teleprimary care• Research & Development • Public Health Activities• Health Information Management – Communicable Disease – Non-communicable Disease
  • 8. Current Challenges in Malaysian Health System1. Lack of integration2. Changing trends in disease pattern & socio - demography3. Greater expectations from public4. Dependency on govt. subsidised services – Issues of economic inefficiency5. Limited appraisal & reward systems for performance6. Conflicts of interest7. Accessibility & affordability - Discrepancy of health outcomes8. Limited coverage of catastrophic illness e.g. haemodialysis, cancer therapy, transplants etc.9. Private spending for health overtaken public since 2004 8
  • 9. Public Private Expenditure on Health, 1997-2007 (2007 RM Value)Source : MNHA (2007) 2.6 18,000 2.5 2.4 2.4 2.1 2.3 2.1 2.1 1.7 1.8 2.1 2.2 2.0 1.6 16,000 1.5 1.9 1.9 16,682 1.6 1.7 1.5 1.6 1.6 1.5 14,360 1.0 14,000 13,034 13,546 0.0 Percentage (%) 12,067 RM million 12,000 11,558 11,542 11,740 10,271 -1.0 10,000 9,083 10,079 8,727 -2.0 8,000 7,320 6,351 7,208 6,000 5,806 6,571 6,824 -3.0 5,616 5,658 5,970 5,538 4,000 -4.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year 9 PUBLIC (RM million) real RM2007 base PRIVATE Public as % GDP Private as % GDP
  • 10. Ratio of Out-of-Pocket (OOP), Public & Private Expenditures100%90% 18.6 23.0 32.0 34.5 32.3 Gen Gov 1.3 44.280% Revenue 14.570% 17.1 Social 7.5 0.7 Security60% 1.8 4.5 0.4 20.8 23.3 External 3.3 7.2 25.650% 0.1 0.4 Resources 7.7 4.1 Other 0.0 4.0 Other40% 12.7 3.7 Private Private 17.5 (Employers)30% 56.3 51.4 Private Private 21.6 40.5 Pooled Insurance20% 30.2 Private 22.510% 14.5 OOP 0% MALAYSIA Low Lower Malaysia (2006) Upper High GLOBAL Income middle middle Income 10 Income Income Source: World Bank, 2005
  • 11. Total Expenditure on Health (TEH) as Percentage of GDP (2005)TEH as % of GDP, 2005 12.0 11.2 10.0 8.6 8.0 6.6 6.0 4.8 4.7 4.2 4.2 4.0 2.0 0.0 Low Income Lower middle Income Malaysia Malaysia (2007) Upper middle Income High Income GLOBAL 11 Source : World Bank, 2005
  • 12. Government Spending on Health as % of Total Government Expenditure (2006) Government Spending on Health as % of Total Government Expenditure252015 7.0%10 Government Spending on Health as % of Total 5 Government Expenditure 0 Source : WHOSIS data 2006
  • 13. Health expenditures per capita, 2009 prices20001800 In the future with no1600 restructuring of the14001200 health system…..1000 800 600 In absence of health 400 financing reform, health 200 system likely to become 0 increasingly privatized… 09 10 11 12 13 14 15 16 17 18 19 both in funding and 20 20 20 20 20 20 20 20 20 20 20 GGHE pc PvtHE pc service delivery…… 2004 2009 2018GGHE 50% 45% 35%PvtHE 50% 55% 65%-PvtOOP 40% 47% Source: Dr Christopher James, WHO-PvtOther 15% 17% WPRO – Projections from MNHA data
  • 14. The Combination of Organisational and Financial Reforms A Nation ChoosesDepends on What Goals A Nation Wants to Achieve
  • 15. Aligning Our Health System To Our Country’s AspirationsNew Economic Model ? Malaysia Economic Monitor: Repositioning for Growth - 4 Key Elements (World Bank, November 2009)1. Specialising the economy - high value-added, innovation-based, strong growth potential, enabling environment internally-competitive appropriate soft and hard infrastructure knowledge economy2. Improving the skills of the workforce – specialised and skilled labour moving up the value-chain, social and private returns to education and skills upgrading, increase productivity3. Making growth more inclusive – Strong inclusiveness policies, equity, helping household cope with poverty through health care4. Bolstering public finances – broaden the country’s narrow revenue base, lessen subsidies, reduce the crowding-out of private initiatives, shift expenditure to areas of specialisation, skills and inclusiveness 15
  • 16. PROPOSED MODEL for MALAYSIA 16
  • 17. 1Care Concept• 1Care is restructured national health system that is responsive and provides choice of quality health care, ensuring universal coverage for health care needs of population based on solidarity and equity
  • 18. 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 18
  • 19. Features of Proposed Model: BETTER than current system• Strengths of current system will be preserved• Stronger stewardship role for MOH & government• Separation of purchaser-provider functions• 1Care - Integration of health care providers & services• More responsive to population health needs & expectation through increased autonomy• Payments linked closely to performance of provider 19
  • 20. DELIVERY SYSTEM & GOVERNANCE
  • 21. FUNCTIONS WITHIN THE RESTRUCTURED HEALTH SYSTEM Professional Bodies Independent bodies -MMC -Drug Regulatory Authority (DRA) -MDC -Health Technology Assessment (HTA) -Pharmacy Board -Medical Research Council (MRC) - Others -Patience Safety Council -Medical Device Bureau MOH -National Service Framework (NSF) (Quality) -National Health Promotion Board NHFA - Food Safety Authority - Others • GOVERNANCE & STEWARDSHIP • POLICY & STRATEGY FORMULATION • STANDARD SETTING MHDS • REGULATION & SERVICE DELIVERY ENFORCEMENT • MONITORING & • PRIMARY CARE EVALUATION • PUBLIC HEALTH • HOSPITAL CARE • RESEARCH • TRAINING • OTHER SERVICES
  • 22. CHANGES TO CURRENT FUNCTIONS OF MOH WITH PROPOSED RESTRUCTURING Professional Bodies -MMC Independent bodies -MDC -Drug Regulatory Authority (DRA) -Pharmacy Board -Health Technology Assessment (HTA) -Medical Research Council (MRC) - Others -Patience Safety Council -Medical Device Bureau -National Service Framework (NSF) (Quality) MOH -National Health Promotion Board NHFA - Food Safety Authority - Others POLICY REGULATION & TRAINING RESEARCH MHDS PERSONAL MAKING CARE PUBLIC MONITORING & ENFORCEMENT HEALTH EVALUATION-Disease -Basic Control -Post-Basic -Patient Safety Enforcement Primary Hospital -HIC Legislation -Food - Services - MNHA Regional Regional Safety & - Research - Surveillance Authority Authority Quality - TCM - H20 Quality -Professionals - TCM - Human - Allied Health -Health Resources -Nursing Education -Drugs Development - Quality - Finance PHCT PHCT PHCT - HTA - Infrastructure & Equipment -HTA - Quality - ICT
  • 23. Scope of Autonomyfor Independent MOH-owned bodies • Not-for-profit • Accountable to MOH • Independent management board • Self accounting – manages own budget • Able to hire and fire • Flexibility to engage and remunerate staff based on capability and performance 23
  • 24. SERVICE DELIVERY & PATIENT FLOW Additional services Patient (Out of pocket or private health insurance) PHCP Refer Private Public Private Hospital Public Admit Receive treatment Return to referring PHCP Home
  • 25. FUNDING & GOVERNANCENHFA MOH MHDS Regional Health Authority PHCT PHCT PHCT Outpatient and Hospital care free at point of service Minimal co-payments e.g. for dental & pharmacy
  • 26. Primary Health CarePrimary 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 to specific PHCP according to location of home/work/schooling• Dispensing of drugs by independent pharmacies• Payment - capitation with additional incentives – casemix adjustments 26
  • 27. 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 – thru x months training from accredited training centres/providers• Over time only Primary Health Care Specialists are allowed to open a PHCP practice• Accreditation of facilities, credentialing and privileging of PHCP will be done 27
  • 28. Hospital Services• Regional arrangement for hospital services & set-up to better serve the needs of local community in each region• Patients referred by PHCP• Autonomous hospital management• Financing through casemix adjustments – ? Global budget for public hospitals – ? Case-based payment for private hospitals 28
  • 29. Human Resource• Integration of public & private health care providers → increase access for population• Gaining of number & skills through integration• Facilitate providers working in both sectors – suitable arrangements have to be developed• Harmonise/equalise remuneration for public & private• Pay for performance - Incentives are being considered to promote performance - Incentives for performance over benchmark, people who work in remote areas
  • 30. Role of Allied Health• Utilisation of allied health personnel will reduce cost & support the role of health professionals• This will contribute towards overcoming the shortage of human resource• In line with 1Malaysia Clinic launched by PM, it is possible for allied health personnel to carry out certain functions, such as: – Preventive care by nurses – Triaging, basic treatment e.g. T&S, STO, etc by nurses & AMOs.
  • 31. Human Resource: Training• MOH still determines the human capital needs of the country• Within integrated system in-service training has to be planned between public & private facilities• ? outsource training to institution or teaching facilities• ? Open system for formal post-graduate training of doctors - Universities need to review current programme• Credentialing & Privileging – Independent Body – e.g. National Credentialing Committee (NCC), Academy of Medicine etc.• Continuing Professional Development (CPD) – Current system • fund - health facilities / self funded – Compulsory – minimum CPD points/per year for APC 31 – Use for recertification.
  • 32. FINANCING 32
  • 33. 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 33
  • 34. A Summary of Ranking of Different Health Financing Methods Equity Risk Reduce Risk Efficiency* Pooling Selection BEST General Rev General General Rev User Fee, OOP, MSA Rev (Low administrative cost but sometimes hard to collect – so higher cost) Social Ins Social Ins Social Ins Social Ins Comm Fin. Comm Fin Comm.Fin Comm. Fin. Private Ins Private Ins Private Ins Private Ins (High Administrative Cost)WORST User Fee, User Fee, --------------- General Rev/ Direct OOP, MSA OOP, MSA Provision (Inefficient ) – Generally – may not be the case in Malaysia *Efficiency factors include technical efficiency and administrative costs.
  • 35. Social Health Insurance• SHI is another financing approach for mobilising funds & pooling risks, earmarked tax• Community-rated, not risk-rated as in private health insurance (PHI) – all are eligible• High levels of cross-subsidization – Rich to poor – Economically productive to dependants – Healthy to ill• 3 distinct characteristics – Compulsory enrollment, payment of premium. – Benefits eligible for those who contribute only – Benefit Package is predetermined 35
  • 36. Social Health InsuranceAdvantages Disadvantages• Pools Risk & Resources • Challenges in coverage of informal• Mobilise funds designated for sector & determining the poor health system - public • Need to have a good administrative acceptance capacity• Planned prepayment - OOP • SHI requires legislation to provide a• Equity legal framework for authorising – payment according to ability to mandatory, earmarked pay contributions – improve equity in access• Promote health system • Need accurate estimates of the development benefits package & costs – health information system • PPM that shifts financial risk of – rational planning of health provision to the provider, e.g. services & resources capitation need to be continuously monitored & evaluated • Abuse of SHI fund may be a threat 36
  • 37. 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• 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 – 2.85% (In 2007 govt spending 2.11%) 37
  • 38. Main Sources of Health Financing 38
  • 39. Total Health Expenditures with and without 1Care restructuring 90,000Constant 2009 prices (millions) 80,000 70,000 60,000 50,000 40,000 30,000 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 No major changes 1Care
  • 40. IMPLICATIONS 40
  • 41. Implications of Proposed System• Public-private integration• Stronger governance role in a slimmer MOH• Defined practice standards• Benefits package• Payment by performance• Registries for providers and patients• Gate-keeping role by primary care providers• Autonomous management public healthcare providers• Services free at point of care – minimal co-pay• Mandatory regular contribution (prepaid) under SHI• More funding of health with increased coverage 41
  • 42. Benefits to Individuals• 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 with specific PHCP• Access for vulnerable group• Better health outcome• Higher work productivity• All (except govt covered groups) will have to pay to be within the system 42
  • 43. Benefits to Employers• Relieve burden to reimburse worker or give loan for medical spending• Relieve burden to cover work and non-work related illnesses (beyond SOCSO)• Pay low contributions to cover employee and family• Reduce administration to process medical benefits• Avoid systems in which unnecessary care leads to higher expenditure e.g. PHI, MCO & Panel doctors• Healthier workforce and higher productivity• All companies have to contribute – ? tax rebate 43
  • 44. Benefits to Health Care Providers • Bridge the gap between remuneration and work load among health workers in the public and private sectors. • Creates more effective demand for healthcare • Re-address distribution of health staffs through the provision of specific incentives. • Defined standards of care • Ensure appropriate competency through training credentialing and privileging • Reduce brain-drain, increase available pool of providers 44
  • 45. Benefits to the Nation• Strengthen National Unity - 1Care for 1Malaysia• Ensure social safety nets for lower & middle income - Reduce OOP at point of seeking care - Address equity & access of care - Ties-in with current policies of govt• Contain rapid growth in health care cost• Stimulate health care market – create more effective demand for health care, multiplier effect• Capitalise on liberalisation and global health care market• Reduce dependence on government 45
  • 46. Cautions & Concerns• Manage change effectively• Need for strategic communication of issues and plan• Longer term planning.• Adequate time for phased implementation including preparation of manpower, ICT & infrastructure• Increase investments to effect change• Acts and Regulations to enable change• Current economic & global situation may not be an ideal time for change but is an ideal time for planning & preparing the groundwork 46
  • 47. THANK YOU 47