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Health Care Transformation –
The Way Forward
Prof Awang Bulgiba Awang Mahmud
MBBS MPH MAppStat PhD FFPH FPHMM FAMM FASc
Deputy Vice-Chancellor (Research & Innovation)
University of Malaya
• Malaysian population of 28.9 million in 2011 (63% between 15
to 64 years old, 32% below 15 and 5% above 65)
• Life Expectancy: male 71.9, female 77.0
• Crude birth rate is 17.5 per 1000 population
• Crude death rate is 4.8 per 1000 population
• Infant mortality rate is 6.8 per 1000 live births
• Maternal mortality rate is 27.3 per 100,000 live births
• Total expenditure on health RM33.7 billion or USD10.8 billion
• Total Expenditure for Health as a percentage of Gross Domestic
Product (GDP) was 4.96% of GDP
2
Health Status of Malaysians (2011)
• Top 3 causes of admissions at public hospitals
• pregnancy and childbirth
• diseases of the respiratory system
• injuries and poisoning
• Top 3 causes of death in MoH hospitals
• heart diseases
• respiratory diseases
• infectious & parasitic diseases
• All childhood immunisation coverage more than 90%
3
Health Status of Malaysians
Awang Bulgiba Awang Mahmud 4
Privatisation of Healthcare in Malaysia
 Share of private healthcare expenditure rising
 5.8% in 1981
 7.6% in 1982
 45.4% in 2009
 Launch of the Privatisation Master Plan (PMP) in 1991
included healthcare for private ownership; 12 public
hospitals were among 149 agencies identified for
privatisation in Peninsular Malaysia
 Proliferation of private healthcare facilities
 174 in 1992
 660 in 2011
5
Awang Bulgiba Awang Mahmud 6
From 1956 to 2011
Awang Bulgiba Awang Mahmud 7
Health facility 1956 2011
Community clinics 26 1,864
Health clinics 16 985
Private clinics - 6,589
Government hospital & institutions 65 146
Private hospitals 50 220
Awang Bulgiba Awang Mahmud 8
Current scope of services in health clinics
Curative Services
Family Health
Dental Services
Nutrition and Dietetics
Health Education/Promotion
Home Nursing, Care of the Elderly
Rehabilitative Services
Environmental Sanitation
Well Women Clinics
Adolescent Health
Community Mental Services, etc
Awang Bulgiba Awang Mahmud 9
The Future of Malaysian Public
Health Care
We face many problems today
Healthcare costs are rising rapidly
Double burden of diseases
Lifestyle & environmental diseases (CVD-related, cancers)
Emerging and re-emerging infectious diseases
40% of doctors serve 80% of population
60% of doctors serve 20% of population
Health research is not optimal
Awang Bulgiba Awang Mahmud 10
Despite our enviable health status
Double burden of diseases
Lifestyle & environmental diseases (CVD-related, cancers)
Emerging and re-emerging infectious diseases
Costly to treat
Curative care taking precedence over preventive care
Suboptimal use of expensive diagnostic & therapeutic
options
Suboptimal preventive care leading to rise in lifestyle
diseases
Awang Bulgiba Awang Mahmud 11
Rising healthcare costs
No national health data warehouse
Poor interfacing between private, public and university
facilities
“Barriers” between private, MOH and university
facilities
Suboptimal use of chip-based Identity Card
Lack of integrated emergency response plan
Fragmented ambulance service
Awang Bulgiba Awang Mahmud 12
Lack of integrated care
We have gone through half a dozen DGs of Health
No NHFS is in sight
Rising healthcare costs makes this problem worse by the day
Rising healthcare costs contributed by
proliferation of private facilities
introduction of expensive curative services over cheaper
preventive services
sub-optimal use of expensive services in private & public sector
We badly need an NHFS & a way to finance the care of a rapidly
ageing population
Awang Bulgiba Awang Mahmud 13
Lack of National Healthcare Financing
System
Awang Bulgiba Awang Mahmud 14
The Malaysian experience (summary)
The government has always been the main provider of
health care in Malaysia
Preventive care has almost exclusively been the
preserve of the government
From the 1950s until recently, the government was
the only one providing preventive care
The private sector has always concentrated on
curative care
We need to be ready …
… for some Grand Challenges of
the Future NOW
Awang Bulgiba Awang Mahmud 15
1. Rise in lifestyle diseases
2. Ageing population
3. Rapidly spreading infectious diseases
The 3 Grand Challenges of the Future
Awang Bulgiba Awang Mahmud 16
Rise in lifestyle diseases (heart disease, cancers) in
tandem with sedentary lifestyles & environmental
changes
Preventive and promotive care is more cost effective
than curative care
We need a healthcare system & healthcare financing
model that recognises this fact
Lifestyle diseases
Awang Bulgiba Awang Mahmud 17
We do not want this to be
commonplace in the future
Awang Bulgiba Awang Mahmud 19
20
By 2035, >10% of Malaysia’s population will be 60
years or older
Health care must recognise this fact and take steps to
prepare for it
The future healthcare system must cater for this group
of people
Ageing population
Awang Bulgiba Awang Mahmud 21
Retirement homes like this may
become commonplace in the
future
Awang Bulgiba Awang Mahmud 23
Emerging and re-emerging diseases pose a major threat to
Malaysians today
Ability to harness all healthcare resources is key to controlling
outbreaks
Rapidly spreading infectious diseases
Origin & spread of the Black Death in Asia
Awang Bulgiba Awang Mahmud 24
Heat-map Visualisation
Published on Apr 20, 2012
This is a heat-map visualization of the prevalence of flu in
New York City, as observed through public Twitter data.
The more red an area is, the more people are afflicted by
flu at that location. Emergent aggregate patterns are
easily discovered with a second-by-second resolution.
Awang Bulgiba Awang Mahmud 26
Infectious diseases spread faster than ever before
Awang Bulgiba Awang Mahmud 27
Let us take a look at how
quickly
… H1N1 spread throughout the world
Awang Bulgiba Awang Mahmud 29
Chikugunya is here
Awang Bulgiba Awang Mahmud
30
All these aided in part by the
fact …
… that almost everyone can fly
Awang Bulgiba Awang Mahmud 32
A NEW healthcare financing model
A WORLD CLASS School of Public Health
Better use of ALL public and private healthcare
facilities during emergencies
Better integration & sharing of data between
agencies
Awang Bulgiba Awang Mahmud 33
What is needed …
A World Class School of Public
Health
Awang Bulgiba Awang Mahmud 34
Malaysia badly needs a world class
School of Public Health
Advanced training for future public health
professionals
Advocacy for a better quality of life
Advisory role to governments & NGOs
Active involvement in niche areas
Awang Bulgiba Awang Mahmud 35
Malaysia’s School of Public Health needs to prepare itself
to meet these Grand Challenges
Staff capabilities will need to increase dramatically
Lifestyle disease expertise
Ageing issues expertise
Real-time spatio-temporal infectious disease modelling
Quick response infectious disease team
Health policy advisory roles
Better working relationship with private healthcare,
universities & other agencies dealing with healthcare
Interfacing of data from other agencies
School of Public Health
Awang Bulgiba Awang Mahmud 36
Expertise
The list of experts in the country needs to grow
The depth of expertise also needs to grow
Malaysia will need to invest heavily in these
areas:
Capacity building
Building up selected resources & facilities
Extending and strengthening collaborative networks
Awang Bulgiba Awang Mahmud 37
Awang Bulgiba Awang Mahmud 38
More funds for preventive care
Awang Bulgiba Awang Mahmud 39
Awang Bulgiba Awang Mahmud 40
21.35
61.12
10.22
1.85 1.62 3.84
% of MOH Budget
PublicHealth
Medical
Administration
Research and
Tech.Support
One-off
Awang Bulgiba Awang Mahmud 41
Preserve of governments
 Some preventive care will always remain the preserve
of the government
 International health
Relates to control of ports and airports
 Control of epidemics will always be the preserve of the
government because
Epidemic control is expensive with no reward
High level labs like BSL3 labs are expensive to build and
maintain
Awang Bulgiba Awang Mahmud 42
A different take on preventive care
 In US preventive care is only now being provided for by
private health care providers
 The reason is probably caused by the rise of managed care
(payments based on capitation)
 In M’sia some preventive care is carried out by GPs
(vaccinations)
 The driving force is not managed care but because it is
profitable
 Hopefully, there will be greater emphasis on preventive &
promotive care within the next 10 years
 The driving force is likely to be a change in the health
financing model
That Malaysian public healthcare of the future will have the
following features:
1. Place greater emphasis on preventive and promotive rather
than curative care to address the epidemic of lifestyle
diseases
2. See greater integration between public and private healthcare
facilities and academia to address the problem of equitable
access and care of an ageing population
3. Be more integrated for better epidemiological control of
emerging infectious diseases and non-communicable diseases
Awang Bulgiba Awang Mahmud 43
I hope …
44
A New Health Care Financing
Model
45
Awang Bulgiba Awang Mahmud 46
A new health care financing model
A change in the financing mechanism
If the financing mechanism changes from the present one
to a more inclusive national healthcare financing scheme,
this is likely to change
Malaysia is unlikely to follow a managed care model
It is more likely to follow a tax-funded health insurance
model
There is likely to be a blurring in the line between public
& private health care
It is my hope that this model will be less likely to reward
use but more likely to reward doctors for keeping their
patients healthy
Awang Bulgiba Awang Mahmud 47
Hopefully the new model …
will be more likely to reward GPs for keeping patients
out of hospitals
this is similar to what is happening in the NHS
whereby Primary Care Trust doctors are rewarded for
keeping patients out of hospitals
this has the same effect as a managed care model
with its payment based on capitation
will integrate the private and public healthcare
facilities so that better use can be made of such
facilities
Awang Bulgiba Awang Mahmud 48
Some challenges will result from
 Consumer perceptions and demands
 Making more consumers prefer primary care rather than specialist care
 Restricting specialist care to those who require it
 Primary Care Physicians
 Making them the gatekeepers of the health care system
 Changing the entire system of health care
 Technology
 Making IT the enabler for all this
 Environment
 Making the environment conducive for this to happen
 Cost of health care
 Making the new healthcare model a reality
 Getting all parties to agree
 Community participation
 Making the community the driving force behind health care
Public health care
Academia
Private health care
Health
Care
Financing
Model
Awang Bulgiba Awang Mahmud 49
We need to think of a new way
to approach our health care
We need to dream BIG
Awang Bulgiba Awang Mahmud 50
Awang Bulgiba Awang Mahmud 51
The future of health care in
Malaysia is uncertain
… but we can do something
about it now
Awang Bulgiba Awang Mahmud 53
Awang Bulgiba Awang Mahmud 54
Awang Bulgiba Awang Mahmud 55
56

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Healthcare transofrmation the way forward

  • 1. Health Care Transformation – The Way Forward Prof Awang Bulgiba Awang Mahmud MBBS MPH MAppStat PhD FFPH FPHMM FAMM FASc Deputy Vice-Chancellor (Research & Innovation) University of Malaya
  • 2. • Malaysian population of 28.9 million in 2011 (63% between 15 to 64 years old, 32% below 15 and 5% above 65) • Life Expectancy: male 71.9, female 77.0 • Crude birth rate is 17.5 per 1000 population • Crude death rate is 4.8 per 1000 population • Infant mortality rate is 6.8 per 1000 live births • Maternal mortality rate is 27.3 per 100,000 live births • Total expenditure on health RM33.7 billion or USD10.8 billion • Total Expenditure for Health as a percentage of Gross Domestic Product (GDP) was 4.96% of GDP 2 Health Status of Malaysians (2011)
  • 3. • Top 3 causes of admissions at public hospitals • pregnancy and childbirth • diseases of the respiratory system • injuries and poisoning • Top 3 causes of death in MoH hospitals • heart diseases • respiratory diseases • infectious & parasitic diseases • All childhood immunisation coverage more than 90% 3 Health Status of Malaysians
  • 5. Privatisation of Healthcare in Malaysia  Share of private healthcare expenditure rising  5.8% in 1981  7.6% in 1982  45.4% in 2009  Launch of the Privatisation Master Plan (PMP) in 1991 included healthcare for private ownership; 12 public hospitals were among 149 agencies identified for privatisation in Peninsular Malaysia  Proliferation of private healthcare facilities  174 in 1992  660 in 2011 5
  • 7. From 1956 to 2011 Awang Bulgiba Awang Mahmud 7 Health facility 1956 2011 Community clinics 26 1,864 Health clinics 16 985 Private clinics - 6,589 Government hospital & institutions 65 146 Private hospitals 50 220
  • 8. Awang Bulgiba Awang Mahmud 8 Current scope of services in health clinics Curative Services Family Health Dental Services Nutrition and Dietetics Health Education/Promotion Home Nursing, Care of the Elderly Rehabilitative Services Environmental Sanitation Well Women Clinics Adolescent Health Community Mental Services, etc
  • 9. Awang Bulgiba Awang Mahmud 9 The Future of Malaysian Public Health Care
  • 10. We face many problems today Healthcare costs are rising rapidly Double burden of diseases Lifestyle & environmental diseases (CVD-related, cancers) Emerging and re-emerging infectious diseases 40% of doctors serve 80% of population 60% of doctors serve 20% of population Health research is not optimal Awang Bulgiba Awang Mahmud 10 Despite our enviable health status
  • 11. Double burden of diseases Lifestyle & environmental diseases (CVD-related, cancers) Emerging and re-emerging infectious diseases Costly to treat Curative care taking precedence over preventive care Suboptimal use of expensive diagnostic & therapeutic options Suboptimal preventive care leading to rise in lifestyle diseases Awang Bulgiba Awang Mahmud 11 Rising healthcare costs
  • 12. No national health data warehouse Poor interfacing between private, public and university facilities “Barriers” between private, MOH and university facilities Suboptimal use of chip-based Identity Card Lack of integrated emergency response plan Fragmented ambulance service Awang Bulgiba Awang Mahmud 12 Lack of integrated care
  • 13. We have gone through half a dozen DGs of Health No NHFS is in sight Rising healthcare costs makes this problem worse by the day Rising healthcare costs contributed by proliferation of private facilities introduction of expensive curative services over cheaper preventive services sub-optimal use of expensive services in private & public sector We badly need an NHFS & a way to finance the care of a rapidly ageing population Awang Bulgiba Awang Mahmud 13 Lack of National Healthcare Financing System
  • 14. Awang Bulgiba Awang Mahmud 14 The Malaysian experience (summary) The government has always been the main provider of health care in Malaysia Preventive care has almost exclusively been the preserve of the government From the 1950s until recently, the government was the only one providing preventive care The private sector has always concentrated on curative care
  • 15. We need to be ready … … for some Grand Challenges of the Future NOW Awang Bulgiba Awang Mahmud 15
  • 16. 1. Rise in lifestyle diseases 2. Ageing population 3. Rapidly spreading infectious diseases The 3 Grand Challenges of the Future Awang Bulgiba Awang Mahmud 16
  • 17. Rise in lifestyle diseases (heart disease, cancers) in tandem with sedentary lifestyles & environmental changes Preventive and promotive care is more cost effective than curative care We need a healthcare system & healthcare financing model that recognises this fact Lifestyle diseases Awang Bulgiba Awang Mahmud 17
  • 18. We do not want this to be commonplace in the future
  • 19. Awang Bulgiba Awang Mahmud 19
  • 20. 20
  • 21. By 2035, >10% of Malaysia’s population will be 60 years or older Health care must recognise this fact and take steps to prepare for it The future healthcare system must cater for this group of people Ageing population Awang Bulgiba Awang Mahmud 21
  • 22. Retirement homes like this may become commonplace in the future
  • 23. Awang Bulgiba Awang Mahmud 23
  • 24. Emerging and re-emerging diseases pose a major threat to Malaysians today Ability to harness all healthcare resources is key to controlling outbreaks Rapidly spreading infectious diseases Origin & spread of the Black Death in Asia Awang Bulgiba Awang Mahmud 24
  • 25. Heat-map Visualisation Published on Apr 20, 2012 This is a heat-map visualization of the prevalence of flu in New York City, as observed through public Twitter data. The more red an area is, the more people are afflicted by flu at that location. Emergent aggregate patterns are easily discovered with a second-by-second resolution.
  • 26. Awang Bulgiba Awang Mahmud 26
  • 27. Infectious diseases spread faster than ever before Awang Bulgiba Awang Mahmud 27
  • 28. Let us take a look at how quickly … H1N1 spread throughout the world
  • 29. Awang Bulgiba Awang Mahmud 29
  • 30. Chikugunya is here Awang Bulgiba Awang Mahmud 30
  • 31. All these aided in part by the fact … … that almost everyone can fly
  • 32. Awang Bulgiba Awang Mahmud 32
  • 33. A NEW healthcare financing model A WORLD CLASS School of Public Health Better use of ALL public and private healthcare facilities during emergencies Better integration & sharing of data between agencies Awang Bulgiba Awang Mahmud 33 What is needed …
  • 34. A World Class School of Public Health Awang Bulgiba Awang Mahmud 34
  • 35. Malaysia badly needs a world class School of Public Health Advanced training for future public health professionals Advocacy for a better quality of life Advisory role to governments & NGOs Active involvement in niche areas Awang Bulgiba Awang Mahmud 35
  • 36. Malaysia’s School of Public Health needs to prepare itself to meet these Grand Challenges Staff capabilities will need to increase dramatically Lifestyle disease expertise Ageing issues expertise Real-time spatio-temporal infectious disease modelling Quick response infectious disease team Health policy advisory roles Better working relationship with private healthcare, universities & other agencies dealing with healthcare Interfacing of data from other agencies School of Public Health Awang Bulgiba Awang Mahmud 36
  • 37. Expertise The list of experts in the country needs to grow The depth of expertise also needs to grow Malaysia will need to invest heavily in these areas: Capacity building Building up selected resources & facilities Extending and strengthening collaborative networks Awang Bulgiba Awang Mahmud 37
  • 38. Awang Bulgiba Awang Mahmud 38
  • 39. More funds for preventive care Awang Bulgiba Awang Mahmud 39
  • 40. Awang Bulgiba Awang Mahmud 40 21.35 61.12 10.22 1.85 1.62 3.84 % of MOH Budget PublicHealth Medical Administration Research and Tech.Support One-off
  • 41. Awang Bulgiba Awang Mahmud 41 Preserve of governments  Some preventive care will always remain the preserve of the government  International health Relates to control of ports and airports  Control of epidemics will always be the preserve of the government because Epidemic control is expensive with no reward High level labs like BSL3 labs are expensive to build and maintain
  • 42. Awang Bulgiba Awang Mahmud 42 A different take on preventive care  In US preventive care is only now being provided for by private health care providers  The reason is probably caused by the rise of managed care (payments based on capitation)  In M’sia some preventive care is carried out by GPs (vaccinations)  The driving force is not managed care but because it is profitable  Hopefully, there will be greater emphasis on preventive & promotive care within the next 10 years  The driving force is likely to be a change in the health financing model
  • 43. That Malaysian public healthcare of the future will have the following features: 1. Place greater emphasis on preventive and promotive rather than curative care to address the epidemic of lifestyle diseases 2. See greater integration between public and private healthcare facilities and academia to address the problem of equitable access and care of an ageing population 3. Be more integrated for better epidemiological control of emerging infectious diseases and non-communicable diseases Awang Bulgiba Awang Mahmud 43 I hope …
  • 44. 44
  • 45. A New Health Care Financing Model 45
  • 46. Awang Bulgiba Awang Mahmud 46 A new health care financing model A change in the financing mechanism If the financing mechanism changes from the present one to a more inclusive national healthcare financing scheme, this is likely to change Malaysia is unlikely to follow a managed care model It is more likely to follow a tax-funded health insurance model There is likely to be a blurring in the line between public & private health care It is my hope that this model will be less likely to reward use but more likely to reward doctors for keeping their patients healthy
  • 47. Awang Bulgiba Awang Mahmud 47 Hopefully the new model … will be more likely to reward GPs for keeping patients out of hospitals this is similar to what is happening in the NHS whereby Primary Care Trust doctors are rewarded for keeping patients out of hospitals this has the same effect as a managed care model with its payment based on capitation will integrate the private and public healthcare facilities so that better use can be made of such facilities
  • 48. Awang Bulgiba Awang Mahmud 48 Some challenges will result from  Consumer perceptions and demands  Making more consumers prefer primary care rather than specialist care  Restricting specialist care to those who require it  Primary Care Physicians  Making them the gatekeepers of the health care system  Changing the entire system of health care  Technology  Making IT the enabler for all this  Environment  Making the environment conducive for this to happen  Cost of health care  Making the new healthcare model a reality  Getting all parties to agree  Community participation  Making the community the driving force behind health care
  • 49. Public health care Academia Private health care Health Care Financing Model Awang Bulgiba Awang Mahmud 49
  • 50. We need to think of a new way to approach our health care We need to dream BIG Awang Bulgiba Awang Mahmud 50
  • 51. Awang Bulgiba Awang Mahmud 51
  • 52. The future of health care in Malaysia is uncertain … but we can do something about it now
  • 53. Awang Bulgiba Awang Mahmud 53
  • 54. Awang Bulgiba Awang Mahmud 54
  • 55. Awang Bulgiba Awang Mahmud 55
  • 56. 56

Editor's Notes

  1. I am always reminded that we are small in stature and my faith has taught me that we must always try our best but put our trust in God