1 Care Concept Caper


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1Care Concept Paper 6 august 2009

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1 Care Concept Caper

  2. 2. EXECUTIVE SUMMARY CONCEPT PAPER FROM THE MINISTRY OF HEALTH 1Care for 1Malaysia: RESTRUCTURING THE MALAYSIAN HEALTH SYSTEMThis paper is presented to introduce the concept of a national health system named1Care, in line with the government‟s 1Malaysia model towards greater unity. Input andguidance of Economic Council members would help improve ideas in this concept paper.With the approval of the cabinet, MOH, with assistance from various partner agenciesand stakeholders, will then undertake further systematic planning towards thedevelopment of a full blueprint for the 1Care national health system within a 2-year timeframe. Phased implementation will be introduced with full evaluation and monitoring toensure that objectives of the 1Care proposal are achieved.2. Malaysia‟s health care system is acknowledged internationally as a successful,modern government-regulated health system that provides effective health services.Despite the accolades received, Malaysia, like many other countries, is apprehensivethat the present system of health care delivery and financing may not be sustainable inthe long term.3. The country faces several issues and challenges in order to put the population atthe forefront of health services and to increase the system performance and advancequality of care. These challenges include ensuring that services provided meet clients‟need; enhancing performance to improve equity of service; providing higher quality care;and overcoming limited and mismatched health care resources such as human resource,financial and physical infrastructure. 1
  3. 3. 4. Malaysia‟s health care financing pattern mimics more that of lower and lower-middle income countries while in reality we are an upper middle-income country strivingfor high wage earning status. It is now timely to restructure the system in order to alignperformance to the needs and expectation of the nation.5. 1Care is the restructured national health system that is responsive and provideschoice of quality health care, ensuring universal coverage for the health care needs ofthe population through the spirit of solidarity and equity.6. The proposed restructured Malaysian Health System will retain the existingstrengths of the current system. MOH will be streamlined to focus mainly on governanceand stewardship, and specific community health services. The daily task of patient carewill be devolved under an autonomous Malaysian Healthcare Delivery System withintegration of public and private health care providers and services congruent with the1Care concept. These changes will lead to more competition between the providers,higher quality and greater efficiency. The restructured system will be more responsive topopulation health needs and expectations through increased autonomy. Some functionswill be placed under independent organisations owned by and accountable to the MOH.7. The linchpin of the restructured health financing system is the contribution byindividuals and companies into a social health insurance (SHI) fund publicly managed ona not-for-profit basis. SHI premiums are estimated at 9.5% of household income, withcontributions from the government, employer and employee. Two options in theproportion of contributions are submitted for consideration. The National HealthFinancing Authority (NHFA) will safeguard the integrity of the system, its effectiveness tocontrol the rate of health care cost increases and ensure the equitable financing anddelivery of health services.8. Overall spending for health will increase from 4.7% of GDP in 2007 to anestimated 6.2% of GDP. Nevertheless, government subsidy on health care will reducefrom an estimated 17.9% of TEH in 2007 to 15.6% in the proposed system throughimproved targeting of vulnerable population.Prepared by:Ministry of Health6 August 2009 2
  4. 4. ContentsEXECUTIVE SUMMARY ............................................................................................................................1CONCEPT PAPER FROM THE MINISTRY OF HEALTH .....................................................................4OBJECTIVE ..................................................................................................................................................4BACKGROUND ............................................................................................................................................4 Current Health System ............................................................................................................................4 Achievements ...........................................................................................................................................6 Government‟s Commitment ....................................................................................................................7 Challenges in the Current Malaysian Health System .........................................................................8FEATURES OF THE PROPOSED RESTRUCTURED MODEL ........................................................17FINANCING ARRANGEMENTS, COST & FINANCIAL IMPLICATIONS..........................................22CAUTIONS AND CONCERNS ................................................................................................................28BENEFITS ...................................................................................................................................................29 Benefits to the Nation ............................................................................................................................29 Benefits to the People ...........................................................................................................................30 Benefits to Health Care Providers .......................................................................................................31CONCLUSION ............................................................................................................................................31REFERENCES ...........................................................................................................................................32ANNEXES ...................................................................................................................................................34 3
  5. 5. CONCEPT PAPER FROM THE MINISTRY OF HEALTH 1Care for 1Malaysia: RESTRUCTURING THE MALAYSIAN HEALTH SYSTEMOBJECTIVE1. The objective of this concept paper is to propose a restructured national healthsystem that will meet and sustain the future needs of the country. It introduces theconcept of 1Care in line with YAB Prime Minister‟s vision of 1Malaysia. 1Care is therestructured national health system that is responsive and provides choice of qualityhealth care, ensuring universal coverage for the health care needs of the populationbased on the spirit of solidarity and equity.2. The purpose of tabling this concept paper is to seek input and comments from theEconomic Council members. It is also to get approval to develop a detailed blueprint forthe restructured national health system.BACKGROUNDCurrent Health System3. Malaysia has a dichotomous health care system where comprehensive healthcare is offered by a government-led public sector co-existing with a thriving private sector(Annex 1). The latter caters mainly for the personal care of individuals while the formerprovides for both personal care and public health services to ensure overall populationhealth. There are many different financers and providers of health care serving variouspopulation sub-groups. Nevertheless, the Ministry of Health (MOH) remains the mainprovider and financer of health care in the country. 4
  6. 6. 4. There are glaring imbalances and mismatches between the public and privatesector in terms of resources and workloads. In 2008, although only 11% of primary careclinics are publicly owned, they handled 38% of total patient visits. While there are morehospitals in the private system, the reality is 78% of hospital beds remain within thepublic system, attending to 74% of admissions. Through concerted effort, 55% of doctorsare now within the public system. Despite the greater workload for providers in the publicsystem, more resources are spent through private financing (Figure 1). Figure 1: Public-Private Sector Resources and Workload (2008) Health clinics (with doctors) 802 6371 Outpatient visits (m) 38.4 62.65 No. of Hospitals 143 209 Hospital Beds 41249 11689 Admissions 2199310 754378 Doctors (excl. Houseman) 12081 10006 Health Expenditure (RM billion) (2007) 13.54 16.68 Public Private 0% 20% 40% 60% 80% 100% 10 Source: Health Informatics Centre (HIC)5. A national referral system has been established within the MOH to provide asystematic assessment and treatment of patients, along the continuum of appropriatecare. Patients access primary health care providers as the first point of contact and arereferred up to higher levels as needed. Cases are returned to the primary care providersfor follow-up, once close secondary or tertiary attention is no longer necessary. Despitesome bypassing in the public sector, there is a pre-determined referral system tosecondary or tertiary care, with primary care providers acting as gatekeepers (Annex 2).However, bypassing is rampant in the private sector where patients self-refer freely into 5
  7. 7. any level of care (Annex 3). The practice of doctor-hopping among certain patients is amatter of concern, as it does not promote prudent and desired health care practices.Achievements6. Malaysia‟s health care system is acknowledged internationally as a successful,modern government-regulated health system that provides effective health services(Bloom G & Standing H, 2008). Malaysia has achieved notable successes in healthstatus and the health sector including:  reduction in morbidity and mortality and increasing lifespan of citizens;  an equitable public health sector;  universal access to a comprehensive government health sector;  an effective safety net for catastrophic expenditure for chronic illnesses;  minimal or no co-payment for services within the public system;  health service focused on health promotion and disease prevention; and  private sector responsive to market forces.7. Since Independence, Malaysia has achieved great improvement in health asreflected by certain key health indicators. Life expectancy at birth for both genders hasincreased over the years, rising from 56 years for males and 58 for females in 1957 to 72years for males and 76 years for females in 2006. (WHO, 2007). Infant mortality rate,which is a good indicator of overall health system performance, reduced drastically tolevels comparable to developed countries. Nevertheless, Malaysia‟s health indicatorshave plateaued over recent years, compared to other countries, some of whom investmore into their health systems (Figure 2). 6
  8. 8. Figure 2 : Selected Vital Statistics, Malaysia 1957-2006Government’s Commitment8. The Government of Malaysia (GOM) has been committed, both conceptually andoperationally, to progressively improve the health and quality of life of Malaysians. TheMinistry of Health (MOH) strives to provide accessible, equitable and high quality healthcare to the population. Various public documents state the Government‟s role andresponsibility on health, notably the following:  Article 74(1) of the Federal Constitution stipulates that the Federal Government has the authority to legislate health matters. (GOM, 2002)  Vision 2020 states (among others) the aim to ensure the Nation provides adequate access to health facilities (Mahathir M, 1991).  Chapter F (Medical 1974) of the General Order for the Civil Services incorporates the proviso for free medical benefits for civil servants and dependants at public facilities only (GOM, 2006);  The EPF Act 1991 initiated the Employees Provident Fund (EPF) as a compulsory savings scheme for non-pensionable employees and includes provision allowing withdrawal of a portion for medical treatment (GOM, 1991). 7
  9. 9.  Malaysia is a signatory to the Universal Declaration of Human Rights (1948) (General Assembly, United Nations) wherein Article 25 states that “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including … medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, … in circumstances beyond his control. Motherhood and childhood are entitled to special care and assistance”.  Since the Fifth Malaysia Plan, Malaysia‟s 5-year Development Plans have included statements on cost sharing through health care financing mechanisms to provide wider choice and better quality of health services. Although efforts to study the sustainability and eventual introduction of a suitable financing scheme to replace the present one began in the 1980s, to date they have not lead to substantive action. Various reasons may have contributed to the inertia such as timing, political will, readiness of the government, people‟s acceptance and enabling infrastructure to accommodate the change.Challenges in the Current Malaysian Health System9. Despite the accolades received, Malaysia, like many other countries, isapprehensive that the present system of financing may not be sustainable in the longterm, given the rapid rise in health care spending and the high out-of-pocket proportionof this spending. Furthermore, the country faces several issues and challenges in orderto put the population at the forefront of health services and to increase the systemperformance and advance quality of care. The main challenges are:  to ensure services provided meet clients‟ need;  to enhance greater performance;  to enhance equity of overall service delivery;  to ensure higher quality of care; and  to overcome limited and mismatched health care resources such as human resource, financial and physical infrastructure. 8
  10. 10. Challenges in Serving the People Better10. In striving to provide better services to the community, the public health caresystem faces the constraints of higher consumer expectations, epidemiological andsocio-demographic shifts towards an aging population and the changing attitude towardslifestyle, as well as a fairly rigid central administrative structure. The most commoncomplaint received by the MOH is the long waiting time for services and medicalprocedures at all levels of the system. Greater expectations and demands are thenatural evolution of better education, higher income, and more access to information.Changing trends in socio-demography and disease patterns present a major challenge inthe containment of health care cost (Figure 3 and 4). Figure 3: Changing Demographic Trends Source: Department of Statistics 9
  11. 11. Figure 4: Changing Disease Trends in Peninsular Malaysia (1970 and 2008)11. The elderly are living longer as evidenced by an increase in life expectancy. Anincrease in the aged population is associated with an increase in the prevalence of illhealth mainly chronic problems which require long term and continuous care. Elderlypatients are more likely to be admitted with serious and life threatening conditionsentailing high cost. The cost of health care will increase as the elderly populationincreases in the future.Challenges in Achieving Greater Performance12. While the population has benefited greatly from the publicly funded health system,there are growing issues of inefficiency in the targeting of limited health funds.Government spending on public health services benefit even those who can afford to payfor care leading to leakages of public subsidy. Data from the National Health MorbiditySurvey II (NHMS II, 1996) showed that among the richest quintile of the population, morethan half (54%) still admit into public hospitals. It is necessary to encourage the rich toutilise public facilities because they provide the much needed voice to counter-check thesystem and maintain the critical patient mix. Nevertheless, leakages of public subsidycan be circumvented if the affluent are required to pay amounts commensurate withservices rendered. 10
  12. 12. 13. The issue of limited appraisal and reward for performance in the public system stillneeds to be addressed. Poor working conditions, lower remuneration and rewardscoupled with heavy workload contributes to the continuous brain drain of experts andexperienced staff from the public to the private sector and overseas. A less recognisedproblem is the high payment charged in the private sector even when care delivereddoes not meet acceptable standards. When the MOH tries to tackle such mattersthrough legislation and enforcement, it is accused of conflicts of interest as MOH itself isboth the regulator and provider of services.Challenges in Improving Equity14. In health care, both horizontal and vertical equity are relevant. Those with equalneed should receive equal care, while payment should be according to capacity to pay.Moreover, such payment should not be required at the time of use but through a regularprepayment mechanism. Regardless of the wide network of public and private sectorfacilities in Malaysia, its distribution is unbalanced. Private facilities are concentratedmainly in urban areas. Specialist services are available predominantly in larger towns.Hence, rural communities do not receive comparable services. This has contributed tothe discrepancy of health outcomes between urban and rural population as shown inTable 1. Table 1: Discrepancy in health outcomes by geographical location Source: National Health and Morbidity Survey (NHMS) III, 200615. Preferences for seeking care at various facilities are clearly income dependent(Figure 5). When people earn more, they preferentially switch to seeking private health 11
  13. 13. care. As Malaysia strives towards becoming a high-wage earning country, the relevanceof the public health system, as it exists now, is a major concern. Service charges atpublic health facilities (both primary and hospital care) are nominal and may even bewaived on appeal. However, frequent media solicitations for financial assistance forhealth care indicate a weakness in the system. There is a need to increase theresponsiveness of the health care system and health providers to meet the needs andexpectation of the population. Figure 5: Health care Utilisation by Income government private Government Private 100.0 100.0 90.0 90.0 80.0 80.0 70.0 70.0 Prevalence 60.0 60.0 50.0 50.0 40.0 40.0 30.0 30.0 20.0 20.0 10.0 10.0 0.0 0.0 Less than RM400 - RM700 - RM1000 - RM2000 - RM3000 - RM4000 - RM5000 & Less than RM400 - RM700 - RM1000 - RM2000 - RM3000 - RM4000 - RM5000 & RM400 RM699 RM999 RM1999 RM2999 RM3999 RM4999 above RM400 RM699 RM999 RM1999 RM2999 RM3999 RM4999 above Ambulator y care Hospital care Income Range Source : NHMS III, 200616. Since 2004, private spending on health overtook public spending (Figure 6). Theproportion of private sector expenditure has increased from 24% (Health ServicesFinancing Study, 1985) to 55.2% (HIC, 2009). This pattern does not augur well for thehealth system because it has been shown that when majority of health care is privatelyfunded, there is less control on health care inflation. Consequently, cost of health care insuch situations will rise even faster (World Bank Institute,2007). 12
  14. 14. Figure 6: Public-Private Expenditure on Health, 1997-2007. Real RM Value (2007) Source : MNHA (2007) &Public Private Figure 6: HIC (2009) Expenditure on Health, 1997-2007 2.6 18,000 Real RM Value (2007) 2.3 2.4 2.5 2.4 2.1 2.1 2.1 1.8 2.1 2.2 2.0 1.6 1.7 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 Percentage (%) 0.0 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 6,824 -3.0 5,616 6,571 5,658 5,970 5,538 4,000 -4.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Year PUBLIC (RM million) real RM2007 base PRIVATE Public as % GDP Private as % GDP 2817. Of greater concern is the pattern of spending for health in Malaysia (Figure 7).Malaysia is noted to have very high out-of-pocket spending. At the time of illness andvulnerability, people have to ensure that they have enough funds to seek care not only inthe private system, but also in the public system where purchases of certain prescribeddrugs, prostheses and equipment are not subsidised by government funds. This doesnot provide adequate risk protection from possible impoverishment as a result of seekingcare during episodes of catastrophic illness such as cancers, renal failure and majorcardiovascular conditions. 13
  15. 15. Figure 7: Ratio of Out-of-Pocket (OOP), Public & Private ExpendituresPERCENTAGES Source : World Bank, 2005 COUNTRIES 18. There is some risk pooling mechanism available in the private sector in the form of voluntary private health insurance (PHI). These commercial for-profit organisations offer risk-rated insurance packages which are mainly affordable to healthy young financially independent people. Those who are in most need of financial security when seeking care such as the elderly who are not economically active and those with long- term chronic illnesses and pre-existing medical conditions, are unlikely to be accepted as insurers will deem them as very high risk. The PHI industry has grown tremendously in Malaysia in recent years. Unfortunately, to the health economist, this spells yet more bad news as PHI is another proven factor contributing to high health expenditure (World Bank Institute, 2007). 19. Malaysia‟s financing patterns mimics more that of a lower or lower-middle income country while in reality we are an upper middle-income country striving for high wage earning status. In these latter countries, social security infrastructure plays a significant role to garner private capacity into publicly managed fund-pooling mechanisms. In Malaysia, statutory bodies such as the Employee Provident Fund (EPF) and Social 14
  16. 16. Security Organisation (SOCSO) have only a minimal role in providing this socialprotection in health financing.Challenges in Quality of Care20. The dichotomy of public and private provision has had a major impact on thequality of care between the two sectors. Variations arise from the significant differencein infrastructure, such as facilities and equipment, as well as the clinical practice andcompetency of providers and ancillary staff. Such variations have significant impact, notjust on perceived quality but more critically patient safety.21. At the same time, the unregulated growth of medical technology as well as itsready assimilation into the private sector contributes not only to quality concerns but hasalso been proven to contribute to the rising cost of health care (Annex 4). The MOHHealth Technology Assessment (HTA) section reports that of the 115 healthtechnologies assessed from 2004 to mid 2009, only 33% were recommended for routineor selected use, 50% were not recommended while the balance should only be used inthe research environment. Although the introduction of the Private Health care Facilitiesand Services Act (1998) has addressed some of these concerns, there is a need for amore concerted effort regarding the control and distribution of technology as an effectiveway to regulate the availability, use and equitable distribution of cost-effective technologyto achieve higher quality of care.22. A challenge to the harmonisation of quality standards and practices across thehealth system is the lack of information and data sharing. This is further compounded bylow uptake of information communication technology (ICT) to assist clinical practice andevaluation as well management practises.Challenges in Limited Health Care Resources23. In considering resources for any sector, the main components are generallyhuman resource, physical infrastructure and financial resource. Despite efforts toincrease the health care provider numbers in Malaysia, the country still lacks a significantvolume. The current doctor-population ratio of 1:1,255 is higher than the WHO 15
  17. 17. recommendation of 1:1000 (Oji, Utsumi & Uwaje, 2005). Moreover, skilled personnel arenot necessarily distributed according to health needs of the nation (Annex 5). Privatefacilities in particular, responding to higher purchasing power, are concentrated in urbanareas.24. Given the volume of patients that utilise public hospitals, it is not surprising thatovercrowding is an issue that frustrates the government‟s efforts to provide morecreature comfort to patients and visitors. MOH primary health care providers treat morepatients with chronic illnesses compared to private general practitioners (GPs) who treatmore „healthy ill‟ (ACG Project Team, 2007). For public sector specialists, about 70% oftheir patient workload consists of complex cases, compared to 25% for private sectorspecialists (Abu Bakar S. et. al. 1993). In such a stressful environment, it is perhaps notsurprising that there are substantial unhappiness from both clients and staff in the publicsector.25. Although Malaysia is an upper middle income country, its level of healthexpenditure mimics more that of a lower middle income country (Figure 8). The systemis clearly under tremendous pressure. It is time to revamp the situation in order to alignperformance to the needs and expectation of the nation. It is time for “business unusual”.(Mohd. Ismail M., 2009)Figure 8: Total Expenditure on Health as percentage of GDP for Countries according to Income Level (2005) 16
  18. 18. FEATURES OF THE PROPOSED RESTRUCTURED MODELMain Objectives of Restructuring26. Given the many challenges now facing the Malaysian health system, theobjectives of the proposed restructuring are manifold. The newly restructured system willhave to be BETTER than what Malaysians already enjoy today, with enhancement ofuniversal coverage in line with the 1Malaysia philosophy. The concept of 1Care ensureshorizontal integration between the public and private sectors and vertical integrationbetween the various levels of care within the health care delivery system. Through thisintegration, the development of a national health system will promote greater technicaland allocative efficiency.27. Health services will become more affordable through a publicly-managedprepayment scheme, designed to ensure sustainability and appropriateness of thesystem to the needs of a progressive nation. The restructuring will undertake measuresto improve equity in terms of access to better quality of care and financial risk protection.This includes effective safety nets for catastrophic spending due to illness in aresponsive and caring health care system.28. It is envisaged that increased personalised and community care will lead togreater client satisfaction and health outcomes. A more conducive work environment willeventually lead to the reduction of the brain drain of highly skilled health care personnelfrom the country and from the public to the private sector.Features of the proposed restructured model29. The proposed restructured Malaysian Health System will retain the existingstrengths of the current system. The role of the MOH will be more streamlined in 3broad functions:  Governance and stewardship  Selected public health services  Personal health care services devolved to the Malaysian Healthcare Delivery System (MHDS)30. Its main focus within the new public health functions would be the governance andstewardship of the national health system. The role of community health services and 17
  19. 19. the function of communicable disease control are critically important as witnessed by thecurrent pandemic of H1N1 Influenza 2009 ravaging our country and indeed the world.This public good will remain protected and guaranteed as it remains within the MOH, butwith a more specialised role. The MOH of the future will be managed as a tight ship ofhighly skilled senior experts, functioning cohesively in a matrix organisation.31. The daily routine of patient care will be devolved under an autonomous MalaysianHealthcare Delivery System (MHDS). The formation of MHDS will change the healthcare system in two major aspects:  the separation of purchaser-provider functions from MOH, allowing the role of MOH in governing and financing the health system to be more effective and with fewer issues pertaining to conflict of interest; and  the integration of public and private health care providers and services congruent with the 1Care concept.32. In the restructured system, Primary Health Care (PHC) will be the thrust of healthcare delivery in Malaysia. This change will result in better collaboration between publicand private providers who now perform on equal footing, utilising similar care pathwaysand performance tools; thus leading to higher quality and efficiency. The MHDS will bemore responsive to individual health needs and expectations through increasedautonomy. To this end, some functions will be placed under independent organisationsowned by and accountable to the MOH. These autonomous bodies, which are run bytheir own management board, will have the flexibility to engage and remunerate staffbased on capability and performance. Staff and facility performance will also be the maincriteria for service payments.Functional Relationship of the proposed restructured model33. The schematic in Annex 6 highlights the functions of the restructured healthsystem. This paper is designed to introduce the broad skeletal concepts of 1Care andthe restructured health system. The substance of the structure and detailedorganisational arrangements will be developed in a blueprint for the restructured systemwhen general approval to proceed is secured.New Public Health Functions 18
  20. 20. 34. The New Public Health Functions denoted in the chart includes policy andregulations, public health services and any other services deemed necessary.The Policy & Regulation function includes those related to the following:  Policy and Development - responsible to formulate and review all national level policies related to the health system planning including (but not confined to) standard setting, quality assurance, guidelines for good practice and adoption of cost-effective measures, infrastructure development, training needs, research, ethics, ICT support. These functions will apply to the various scope of health such as hospital care, disease control, family health, oral health, health promotion, pharmacy services, nutrition, engineering, and other areas of concern.  Regulatory body – specialised function mainly to formulate and review all legislations related to health care providers, health care practice and premises, marketing and use of medical equipment, pharmaceuticals and other medical and health products. Public Health, Medical Practice, Oral Health, Drug and Pharmacy, Medical Devices, Health Facilities, Food Safety, Traditional and Complementary Medicine, and Research. Emphasis will be placed on the clear delineation of function and responsibility for legislation and regulation so that oversight and enforcement will be effective and impartial to avoid conflicts of interest. Where appropriate, different aspects of enforcement may remain within the MOH or devolved to independent bodies.  Monitoring and Evaluation – to ensure restructuring of the health system will meet specific objectives. Performance of autonomous bodies will be monitored and evaluated. Quality and standards established by the Government will be implemented so that the people receive appropriate and satisfactory health services. Aspects such as health care provider assessment which encompass accreditation, credentialing and others will be given attention. Health quality control implementation will be carried out jointly with professional health bodies. In areas where there are legislation involving establishing of facilities and services, such as health care facilities and laboratories, assessment and monitoring in terms of „zoning‟ or issuance of „certificate of needs‟ will be required. There may be quota assessment before an approval is given.35. The Public Health Services function will focus on issues related to theimplementation of community based Public Health Services mainly focused onCommunicable Disease Control, community level disaster management and others.Communicable Disease Control related services like Public Health Laboratory services 19
  21. 21. will be retained within the MOH. These services will be provided throughout the countrywithin the existing public health network.Malaysian Healthcare Delivery System (MHDS)36. The MHDS will be the implementing arm in the delivery of personal care. Itcomprises of several Regional/State Authorities to address regional health needs. Theyare responsible for the strategic supervision of the following functions:  developing plans for improving health services in their local area,  making sure local health services are of a high quality and are performing well,  increasing the capacity of local health services so they can provide more services, and  making sure national priorities for example, programmes for improving cancer services are integrated into local health service plans.37. The MHDS does not raise its own funds. Funding of MHDS activities relateddirectly to personal care will be obtained from the National Health Financing Agency(NHFA) based on pre-determined criteria set by the NHFA in collaboration with the MOH.Primary Health Care Trust (PHCT)38. Primary Health Care Trust (PHCT) is an autonomous agency accountable to theMHDS. It administers personal care as the key agency to purchase primary health careservices and other levels of services for the region. They are responsible for providingpersonal care and preventive services. They oversee and purchase health care servicesfrom independent contractors (Primary Care Providers/Contractors), dentists andpharmacies. They also commission services from secondary or tertiary care providerssuch as hospital services, emergency services, etc.Primary Health Care Providers (PHCP)39. Primary health care services will become the foundation of the health serviceswith strong focus on promotive-preventive care and early intervention. PHCP comprisesmedical practitioners and dentists, assisted by nurses and appropriate paramedicalpersonnel, in public and private clinics operating individually or as registered groups toprovide services under the financing scheme. The primary health care providers who are 20
  22. 22. independent contractors will function as family doctors and dentists, who aregatekeepers to secondary and tertiary care. Every individual in the population isregistered with a PHCP. Financing of medical services is by capitation with case-mixadjustments (based on the community‟s health profile). There are also additionalincentives for achieving performance targets and as inducement for working in lessdesirable areas. The benefit package of services will be developed and other paymentmechanisms apply for dental treatment and pharmaceutical prescriptions where patientswill make some co-payments when receiving service. These co-payments are institutedto encourage prudent use of these services. Certain identified groups, such as the poor,will be exempted from these co-payments.Hospital Services40. In the restructured system, patients will be referred by their PHCP to higher levelsof care, except in emergencies. There will be a regional network of autonomous publichospitals, based on distribution of expertise and sub-expertise available in everyzone/state/district. The PHCT purchases hospital services from either the public networkor private hospitals. The services provided by public hospitals, will be funded through aglobal budget based on case adjustments using Diagnostic Related Groups (DRG).Financing of the private hospitals services is through case-based payment.National Health Financing Authority (NHFA)41. NHFA will be an autonomous statutory body, accountable to MOH. It will not beprivatised to safeguard the integrity of the system, its effectiveness to ultimately controlthe rate health care cost increases and ensure the equitable financing and delivery ofhealth services to the Nation. It shall manage both the social health insurance andgeneral taxation fund for personal health care as a single fund manager. Funds will bedisbursed to the regional/state health authority based on specific and transparentformulas to cover the personal health care needs of that population. The NHFA will beaccountable for the management of the overall health financing system in closecollaboration with the MOH and MHDS. The main responsibilities of the NHFA include:  Design Benefits Package together with MOH, MHDS and PHCT  Negotiating with government for funding required to provide the agreed benefits package  Monitor the fiscal performance of agencies within MHDS 21
  23. 23. Independent and Professional Bodies42. Within the restructured health system, several existing independent andprofessional bodies with specific technical functions will be strengthened while new onesmay be established. These autonomous agencies are set up to ensure that the systemwill be more responsive to client needs. In some situations, they serve as regulatoryfunctions for licensing and enforcement.FINANCING ARRANGEMENTS, COST & FINANCIALIMPLICATIONS43. In the proposed system, current financing arrangements will also be restructuredto ensure better financial risk management, equity in financing of health care, greaterefficiency of government subsidy for health care and accountability of work performance.The proposed financing scheme moves the current Malaysian financing picture, asdescribed earlier (Figure 8), more into an upper middle to higher income country pattern.44. Health care will continue to be financed through a combination of mechanisms butwith greater public financing, thus reversing the trend of private individual financing seenpreviously (Figure 6). Major components for health financing will now be publiclyadministered social health insurance (SHI) and general taxation, with much smallercomponents of private spending. Private spending may consist of out-of-pocket spending(OOP) to pay the minimal co-payments at point of seeking care e.g. for dispensing ofdrugs and dental treatment within the SHI benefits package, and for services not coveredby SHI. Private spending will also include voluntary top-up private health insurance (PHI)and corporate spending for employees for coverage of high end care and other non-SHIcovered items.45. SHI contribution in the proposed system is mandatory with contributions for thepremiums raised from employer, employee and the government of Malaysia (GOM). Thewhole population of Malaysia has to subscribe to SHI with no avenue to opt-out from thesystem. This will ensure a high level of risk pooling and equity in financing for health 22
  24. 24. whereby the healthy will cross-subsidise the ill, the rich cross-subsidise the poor, and theeconomically productive cross-subsidise the dependant. SHI premiums are calculated asa percentage of income and shared by employer, employee and government funding.This model of nationally pooled financing will further enhance social unity and caring asper the 1Malaysia concept. To ensure greater equity and lower average premiums, SHIpremiums are estimated through community risk-rating to cover all family members, andnot individual risk-rating as in PHI. The latter will result in unacceptably high premiumsfor those with the greatest health care needs and yet have the lowest capacity to financethis need, and these are mainly the young and elderly. The estimates for financing in therestructured system are shown in Table 2 below.Table 2: Estimates for financing for the restructured systemEstimated Annual Cost to Finance Malaysian Health System (RM) Expenditure for personal health care (PHC, specialist & inpatient care) 27.87b As % of GDP 3.9% Estimated Total Expenditure on Health with 5% administrative charge 44.23b(Includes personal health care, public health, training, research, privateinsurance etc.) As % of GDP 6.2% Per capita expenditure for personal health care 984.44 Per capita expenditure for all health services 1,562.60 SHI Premium for personal health care 972.44 SHI Premium for average household (HH) 4,181.50 SHI Premium as % of average household income 9.5%46. All estimates are made based on the assumption of population averages forannual utilisation and cost. Primary health care visits are estimated for 6 annual visits perperson. Specialist clinic visits are estimated on 0.78 utilisation rate and inpatient care on0.09 utilisation rate (NHMS II). The Malaysian population is estimated as 28,306,700(Department of Statistics, 2009). Average household size is 4.3 persons per household 23
  25. 25. (Department of Statistics, 2006). Unit cost estimates are RM40, RM317.39 andRM5088.16 for a primary care visit, a specialist visit and an inpatient episoderespectively. A low 5% administration is estimated for the running of the system atsteady state capitalising on economies of scale and prudent government management.47. Funding contributions by employer and employee is a key feature of SHI as amove towards greater social solidarity. There is no accepted gold standard on how toapportion government, employer and employee contributions to SHI premiums (Annex7). We propose 2 options in funding contribution of either 2/3 employer and 1/3employee participation as the preferred Option 1, or 50:50 contribution as Option 2.Option 1 is recommended given that majority of income tax collection for Malaysia israised through corporate tax rather than personal income tax and companies are alreadyspending substantial amounts privately to provide health care benefits to theiremployees. The 2 options are presented schematically in Figure 9. Nevertheless, thesefigures remain preliminary estimates and further analysis and estimates will berecalculated when the decision is taken to proceed further with the planning forrestructuring.Figure 9: Funding options for Employer-Employee contribution to SHI Premiums.48. With the proposed financial restructuring and the expansion of the social securityfund for health, beyond the current minimal health care spending through organisationssuch as Employee Provident Fund (EPF) and Social Security Organisation (SOCSO),public financing will increase from about 44% of total expenditures on health (TEH) to 24
  26. 26. 76% of TEH, if the whole Malaysian population participates in the SHI programme. Thisis demonstrated in Figure 10.Figure 10: Main Sources of Health Financing49. International experience has shown that countries with majority public funding forhealth care is better able to control the rate of health care cost increases through greaterfinancial management, economies-of-scale and the bargaining power of a monopsonynot-for-profit organisation. Comparative analysis of the financing arrangements for boththe current and the restructured health system is made in Annex 8.50. The GOM remains committed to funding of health services in the restructuredsystem but with better targeting of beneficiary groups. This will reduce the use ofprecious government funds by those of higher income who can afford to fund their ownhealth needs. Thus government subsidies for health care will be targeted to vulnerablegroups. Through general taxation, the GOM will subsidise funding of primary health careservices for the whole Malaysian population. At the same time, government will alsosubsidise SHI contributions for identified vulnerable population groups such as the poor, 25
  27. 27. disabled, and the elderly. As the largest employer in the country, the government will beexpected to contribute to the insurance premiums of government pensioners, civilservants and five dependants. The GOM will also fund for various other componentsparticularly items which are public goods and merit goods such as community healthmeasures e.g. communicable disease control, health education, environmental healthissues and in-service training for public health care providers. Funding for other itemssuch as public infrastructure development and research will be through MOH budget.Estimates for these commitments are shown in Table 3.Table 3: Estimates for Government Spending on Health in the Restructured System51. Therefore, in line with proposal to inject sufficient funds into the health system,government spending for health will increase from 2.11% of GDP in 2007 to anestimated 2.85% of GDP (or from RM13.6billion to RM23.4billion in 2007 RM value).However, government subsidy on health care will reduce from an estimated 17.9% ofTEH in 2007 to 15.6% in the proposed system through better targeting of vulnerablepopulation. In absolute quantum, the reduction in subsidies of about 2.3% of TEH isalmost RM1billion.52. The linchpin of the restructured health financing system is the contribution ofprivate spending by individuals and companies into a national fund that is publicly 26
  28. 28. managed on a not-for-profit basis. This arrangement under the National Health FinancingAuthority (NHFA) will not be privatised to safeguard the integrity of the system and itseffectiveness to ultimately control the rate of health care cost increases and ensure theequitable financing and delivery of health services to the Nation.53. Funds to pay for SHI premiums may come directly from employer and employeecontributions as monthly salary deductions, and also through direct contribution by non-formal sector workforce (possibly at a reduced rate to be estimated later). Other possiblesources of fund raising may include EPF dividends, EPF contributions and SOCSOfunds. In line with other government plans to look at contributory pension schemes(pencen bercarum) for civil servants, it is conceivable that civil servants will alsocontribute towards their own SHI premiums as per private employers. If the programmeis adopted, another possible source of funds may come from the Kumpulan WangAmanah Pencen (KWAP).54. PHI has been developing steadily in Malaysia providing some risk pooling forhealth care amongst the higher income population. Current private spending for healthof 56% of TEH in 2006 (41% OOP, 8% PHI and 7% corporate and other spendingsources) will ultimately be reduced to 23% of TEH in the reformed system at steadystate. Private spending will not disappear completely as this component allows for thecontinued development of PHI in specific niche areas as a voluntary top-up to themandatory SHI programme. Individuals and corporations may also choose to fund otheraspects of health services particularly the extra hotel-level comforts through some OOPpayments or company expenses.55. For catastrophic spending on conditions not covered in the SHI benefits package,other existing sources of funding will be utilised. Such sources include the MOH HealthWelfare Fund and the government grants given to specific non-governmental agencies toprovide specific services such as the National Kidney Foundation, AIDS Foundation,National Heart Foundation and the National Cancer Council (MAKNA). 27
  29. 29. CAUTIONS AND CONCERNS56. This paper is presented to introduce the concept of a national health systemtermed 1Care in line with the government‟s 1Malaysia policies towards greater unity. Inpresenting this paper to the Economic Council (EC) it is expected that EC members willprovide valuable input and guidance to improve the skeletal plans towards restructuringthe Malaysian health system.57. With the consensus of the Economic Council and approval of the cabinet, theMOH, with assistance from various partner agencies and stakeholders, will thenundertake further systematic planning towards the development of a full blueprint for the1Care national health system within a 2-year time frame. Upon development, phasedimplementation of the programme will be introduced with full evaluation and monitoringto ensure that the objectives of the 1Care proposal are achieved.58. Given the scale of the restructuring, it is imperative that change is managedeffectively at all levels of stakeholders. With further development of the blueprint manymore deliberations with interested parties and stakeholders including the community willbe undertaken to ensure that a solid and widely accepted proposal emerges, taking intoconsideration various aspects of concern. A realistic time frame for phasedimplementation is required to ensure that the requisite manpower, infrastructure and ICTneeds and challenges are addressed. Appropriate training for health care personnelsuch as training in management of public providers and managers in preparation forgreater autonomy has to be conducted. Effective change management will entail initialinjection of investments particularly for the restructured public system in order tocompete with the private sector on similar footing.59. In preparation for expanding the 1Care concept expounded in this paper, acomprehensive review of existing statues and documents will be undertaken to identifyand streamline existing legislations and regulations on the government‟s role andresponsibility.60. It is understood that restructuring towards greater efficiency in health delivery mayrequire rationalisation of services in some regions and its development in others to alsoaddress equity issues. Payment mechanisms, incentives and market signals will lead to 28
  30. 30. change in the distribution of health facilities and the desired changes to ensure higherquality health care practices.61. Planning and execution of the 1Care plan will occur over the longer term. Whilstthe current economic socio-political and global situation may be of concern to effect suchchanges in the short term, nevertheless it is expected that the EC will recognise that nowis the ideal time (and indeed it is warranted) to prepare the necessary groundwork.BENEFITSBenefits to the Nation62. The development of a national health system will strengthen national unitythrough a 2-prong process in which:-  social solidarity is fostered through SHI contribution specifically addressing marginalised segments of the population in accordance with the 1Malaysia effort. There are cross subsidies by the rich to the poor, the healthy to the sick, and the economically productive to dependants and enhancement of corporate social responsibility through employer contribution; and  the 1Care concept emphasises the ethical delivery of health care, employing welfare and extra-welfare economic principles to tackle the obvious market failures of the health system for better efficiency and at the same time, addressing equity issues that troubles the system.63. This programme will stimulate the health care market through increased healthcare spending aligned with Malaysia‟s upper middle income status. With enhancedpublic-private integration there will be increasing productivity and systemresponsiveness.64. The policy will capitalise on the liberalisation and globalisation of the healthcare market and ensure that Malaysia’s health care system remains competitivewith the ability to attract highly skilled medical personnel and support health care travel.At the same time, public funds and subsidies will not benefit foreigners at the expense ofthe Malaysian people. 29
  31. 31. 65. The restructured system reduces unnecessary dependence on governmentfund by decreasing the leakage of government spending to those who can afford. Thissegment of society will contribute through SHI allowing better targeting of limitedgovernment subsidy. As mentioned previously, in 2007, government subsidy forpersonal health care services was 17.9% of total expenditure on health (TEH). With theproposed restructuring, this will be reduced to 15.6% through better targeting ofvulnerable groups, despite enhancement of services.66. The proposed system will improve financial safety nets for lower and middleincome groups through better risk management. There is reduction of direct out-of-pocket spending (OOP) at point of seeking care by prepayment and coverage of thepoor, disabled and elderly through general taxation. Through SHI, the paying populationgains from the large pool of contributors. There will be lower insurance premium andwider benefits. There is assurance that no one is denied coverage due to any existingillnesses or has to pay substantial individually risk-rated premiums due to ill health.67. Public management of majority of the health expenditure will ultimately containthe rapid growth in health care cost and inflation. 1Care promotes greater efficiencythrough various means such as higher quality of care, more cost-effective measures,reducing duplication and increasing competition by attending to the inherent failures ofhealth care market.Benefits to the People68. This proposal was developed with the ethos of serving Malaysians better.Through 1Care, people will get more access to both public and private providers in amove to bring about personalised care nearer to home.69. At the point of physical and economic hardship during illness, individuals are notfaced with the concern of paying large sums or setting up deposits with the guarantee ofminimal co-payments at the point of seeking care. With prepayment into the SHIscheme, there is assurance of access for vulnerable group, and addresses the demandand expectations of the middle-income segment of the Malaysian population. Therestructured system has at its heart the pledge to improve quality of care delivered andclient satisfaction. 30
  32. 32. 70. In the end the pursuit is for greater health outcomes for the community, thusensuring the means to higher work productivity and the ability to pursue individual lifechoices.Benefits to Health Care Providers71. The restructuring will bridge the gap between remuneration and workload amonghealth workers in the public and private sectors. Eventually, the problem of public sectorworkers migrating to the private sector (brain drain) can be overcome. The restructuringoptimises the existing health practitioners in the public and private sectors. The lack ofhealth staff interested in serving less desirable areas can be addressed through theprovision of specific incentives. Training and credentialing mechanisms will bedeveloped to ensure all health practitioners have the appropriate competency, in linewith the care standards to be determined.CONCLUSION72. Malaysia‟s health system has been recognised internationally as an excellentsystem. However, current and future challenges will affect the sustainability andrelevance of the system. Therefore, the restructuring of the country‟s health system iscritical. The proposed health system will have several clear advantages. Citizens, healthpractitioners and the government will obtain multiple add-on benefits. The 1Care conceptis in tandem with the 1Malaysia philosophy to foster greater cohesiveness of theMalaysian population through the national health system.73. The Economic Council is requested to consider and approve the proposedconcept of 1Care through Restructuring of the national health system to enable theMinistry of Health to further its blueprint development.Prepared by:Ministry of Health7 August 2009 31
  33. 33. REFERENCESAbu Bakar S, Wong SL, Jai-Mohan A. et. al., (1993) „Utilisation of specialist medical manpower study 1992/93‟. Ministry of Health and Academy of Medicine, Malaysia.ACG Project Team (2007). Development of Teleprimary Care (TPC) Dataset Through Use of Johns Hopkins ACG (Adjusted Clinical Groups) in Malaysia (Draft). Family Health Development Division, Ministry of Health, Putrajaya. September 2007.Bloom G & Standing H (2008). „Future Health Systems: Why Future? Why Now?‟ Social Science & Medicine 66 (2008), 2067-2075. Retrieved on 31 July 2009 from the World Wide Web: http://www.futurehealthsystems.org/news/GHF/FHSflyer.pdfDepartment of Statistics, Malaysia (2006). „Yearbook on Statistics, 2006’. Percetakan Nasional Malaysia Berhad, 2006.Department of Statistics, Malaysia (2009). „Population Statistics‟. Retrieved on 20 Julai 2009 from the World Wide Web: http://www.statistics.gov.my/eng/index.php?option=com_content&view=article&id=50:pop ulation&catid=38:kaystats&Itemid=11EPF (2009). „Employees Provident Fund- Treating Illnesses’. Retrieved on 20 Julai 2009 from the World Wide Web: http://www.kwsp.gov.my/index.php?ch=p2life&pg=en_p2life_medicalGOM (2002). „Federal Constitution (As At 10th April 2002)’. International Law Book Series, Petaling Jaya. Article 74(1).GOM (2006). „Perintah-Perintah Am dan Arahan Pentadbiran‟. International Law Book Series, Petaling Jaya. Bab F (Perubatan 1974)HIC (2009). „Health Facts, 2008’. Planning and Development Division, Ministry of Health, Putrajaya. May 2009.Institute for Public Health (1997). „The Second National Health Morbidity Survey (NHMS II) 1996’. Ministry of Health, Kuala Lumpur, 1997.Institute for Public Health (2008). „The Third National Health Morbidity Survey (NHMS III) 2006’. Ministry of Health, Kuala Lumpur, 2008. 32
  34. 34. Jeffers, J. (1985). „Health Services Financing Study’, 1984-85. Westinghouse Health System. Asian Development Bank.Mahathir Mohamad (2001). „The Way Forward: Vision 2020‟ Working paper presented at the Malaysian Business Council, Kuala Lumpur on 28 February 1991. Retrieved on 20 Julai 2009 from World Wide Web: http://www.wawasan2020.com/vision/MNHA (2008), Malaysia National Health Accounts: Health Expenditure Report (1997-2006). Planning and Development Division, Putrajaya, 2008.Mohd. Ismail M., (2009). „Healthcare business on the rise‟. Published in The Star on 4 July 2009. Retrieved on 28 July 2009 from the World Wide Web: http://thestar.com.my/columnists/story.asp?file=/2009/7/4/columnists/atyourservice/41324 33&sec=atyourserviceNHI Bureau Taiwan (2004). „National Health Insurance in Taiwan’. Retrieved on 16 July 2009 from the World Wide Web: http://www.unicatt.it/CentriRicerca/Cerismas/Formazione/SGiminiano/2g_Taiwan.pdfOji DE, Utsumi T & Uwaje C, (2005). „International Centres of Excellence for e-Health in Africa with Global University System in Nigeria’. E-Health International. Retrieved on 3 August 2009 from the World Wide Web: http://www.ehealthinternational.org/vol2num1/Vol2Num1 p23.pdfRozita Halina H., (2008). „Asia Pacific Region Country Health Financing’. Institute for Health Systems Research, Malaysia.United Nations (1948). Universal Declaration of Human Rights. Article 25. Retrieved on 20 Julai 2009 from the World Wide Web: http://www.un.org/en/documents/udhr/index.shtmlWHO (2007). „Malaysia Country Health Information Profile’. Retrieved on 4 August 2009 from World Wide Web: http://www.wpro.who.int/NR/rdonlyres/DB90A4E5-0963-4E00-B56C- E09C2AE01ECC/0/19Malaysia07.pdfWorld Bank (2005). „Health Expenditure Data’. Retrieved on 15 May 2009 from the World Wide Web: http://www.who.int/entity/nha/country/Regional_ Averages_by_ WB_Income_group- 2005_En.xlsWorld Bank Institute (2007). „Basics of Health Economics’. World Bank, Washington, 2007. 33
  35. 35. ANNEXES ANNEX 1 Current Malaysian Health System 34
  36. 36. ANNEX 2 Access to Health Providers in Malaysia MOH Other agencies & Private sector SECONDARY/TERTIARY University Hospitals CARE Hospitals with Private Hospitals Subspecialty Hospitals with Specialists Others Medical Corps Hospitals without Orang Asli Specialists Facilities GPs PRIMARY HEALTH Health Clinics/Centres 1 : 20,000 population CARE Rural/Community Clinics 1 : 4,000 population Estate Hospitals without ANNEX 3 Specialists 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 Orang Asli Facilities Specialists GPsPRIMARY HEALTH Health Clinics/Centres 1 : 20,000 population CARE Rural/Community Clinics 1 : 4,000 population Estate 35 Hospitals without Specialists
  37. 37. ANNEX 4MEDICAL DEVICE AND EQUIPMENT IMPORTS IN MALAYSIA (2001-2007) Source ??? Not Frost and Sullivan 36
  38. 38. ANNEX 5 Number of Clinics and Hospitals by State, June 2009 Clinic State Hospital MOH* Private MOH PrivateJohore 352 805 11 28Kedah 281 336 9 11Kelantan 251 185 9 3Malacca 86 278 3 4Negeri Sembilan 143 261 6 7Pahang 306 222 10 8Penang 88 483 6 20Perak 288 619 14 13Perlis 39 32 1 0Selangor 189 1510 10 41Terengganu 172 154 6 1Sabah 270 301 22 3Sarawak 203 303 20 9WP Kuala Lumpur & 14 960 2 30PutrajayaWP Labuan 11 9 1 0Total 2729 6458 130 178* MOH : Health Clinics and Community Clinics only 37
  39. 39. Annex 6Functional Relationship in the Restructured Health System 35 38
  40. 40. ANNEX 7 Country Year % SHI funds % Contribution Employer Employee GDP (multiple/ population (% income) single) covered HIGH INCOME COUNTRIES Single AllAustralia 2005 9.7 (Medicare) Residents 1.5-2.5% Nil 1.5-2.5%Japan 2002 8 Multiple 99% 8 4 4 Single payerKorea 2007 5.6 (NHIC) 97 4-5% 2 2 Single Payer (Bureau for 4.55 (10% byTaiwan 2004 6.17 NHI) 99 govt.) 2.7 (60%) 1.4 (30%) 11.1France 2008 (2008) Multiple (17) 100 19.6 12.8 6.8 MultipleGermany 2008 10.7 (319) - 2003 99.8 16 8 8 National InsuranceUnited (SocialKingdom 2008 9.4 Security) 100 (NI)11 (NI)12.8Netherlands 2008 9.2 Multiple 98.5 7.2 4.8 2.4 5.5Hong Kong 2006 (2002) Nil Nil Nil Nil Nil MIDDLE INCOME COUNTRIES SOCSO (Employment Injury &Malaysia 2007 4.7 invalidity) 16.8 2.25 1.75 0.5Indonesia 2002 2.8 Multiple 10 2.5 (ASKES) 2 0.5Chile 2004 6.1 Single 86 7 Nil 7Philippines 2005 3.3 Single 73 2.5 1.25 1.25Costa Rica 2003 7.1 Single public 88 15 9.25 5.5 4.5Thailand 4 Multiple Mixed (Govt. 1.5) 1.5 1.5Mexico 2002 6.2 Multiple 51% 9.5 6.95 2.95Nigeria 2005 3.9 Single na 15 10 5 Multiple (Main - NHITanzania 2002 8.7 fund) na 6 3 3Mongolia 2002 4.3 Single 77.3 4% (max) 2 2 39
  41. 41. Annex 8 Comparative data of selected countries on Total Expenditure on Health (TEH) Source: WHO (2006) TEH per Govt. HE Public•2008 Figure GDP per capita capita TEH as % (% of HE (%** Based on proposed system US $ of GDP US $ TEH) of TEH)Mid Malaysia (MNHA) 7,221* 245 4.3 44.2 44.6Mid Malaysia (New)** 7,221* 445 6.16 46.1 76.9High Japan 38,443 2,936 7.6 14.6 81.3High Rep of Korea 19,115 973 5.9 11.4 53.0Mid Thailand 3,869 98 3.5 56.0 63.9Mid Colombia 5,440 201 7.3 33.6 84.8Low Vietnam 1,051 37 6.0 17.0 25.7Low Indonesia 2,254 26 2.1 37.0 46.6Low Kenya 895 24 4.5 41.9 46.6High Singapore 37,600 944 3.5 26.5 31.9High Taiwan 17,040 1561 6.17 9.0 66.5Mid Mexico 10,211 474 6.4 17.3 45.5 40