Malaysian Health System: Current Development, Budget 2017 and Future Challenges

INTERNATIONAL CENTRE FOR CASEMIX AND CLINICAL CODING (ITCC-UKM) FACULTY OF PUBLIC HEALTH, KUWAIT UNIVERSITY

Malaysian Health System: Current Development, Budget 2017 and Future Challenges

Professor Dato’ Dr Syed Mohamed Aljunid MD (UKM) MPH ( Singapore) PhD (London); DLSHTM (London); FAMM, FPHMM

Professor of Health Policy and Management Faculty of Public Health

Kuwait University &

Professor of Health Economics & Public Health Medicine National University of Malaysia

Copyright of ITCC-UKM


Outline u Malaysian Health System: Historical

Perspective u Organisation of Malaysian Health System u Roles of Private Providers u Roles of Ministry of Health u Health Financing Scenario u Implications of Budget 2017 u Proposed Solutions To Enhance MHS u Conclusion



Malaysian Health System:

The History u Pre-Independent Period u 13th – 14th Century § Malacca Empire

• Arrival of Arabs Merchants with some form of early modern medicine

u  16th Century – 18th Century § Malacca falls to Portuguese (1511) § Dutch took over Malacca from Portuguese

Occupation (1641) § British occupy Penang (1786)


Hospitals in Malacca

u 1641 - Dutch captured Melaka u Governor: Balthasar Bort u Surgery Clinic - M. Willen

Cornelias Van Alsameer u Hospital - for Dutch citizens § Staff - senior surgeon, 4 junior

surgeons



Pre-Independent Period

u 19th Century § British occupied Singapore (1819) § Malacca, Singapore and Penang

becomes Straits Settlement (1826) § British bring in Chinese to work in tin

mines and Indians to work in rubber estates (1840s) • Health care services in mining area and

rubber estates • Malaria and Beri-beri very common diseases

§ Buildings of Hospitals in major cities


Pre-Independent Period

u 1900 § Institute For Medical Research was

established as “Pathological Institute” •  Sir Frank Athelstane Swettenham, the

Resident-General of the Federated Malay States • Objectives is to “carry out scientific and

sustained research into the causes, treatment and prevention of such scourges as beri-beri and all forms of malaria fevers ”.


Post-Independent

u 1957 § Malaysia gains independent § Ministry of Health established to replace Medical

Services Department under British Colony u Further Development of Rural Health

Services started in 1955. •  Three Tier System

u Start Training of Bidan Kampung by National Family Planning Board in 1969

u 1973 § Gradual conversion of 3 Tier to 2 Tier System






The New Generation

Hospitals

Putrajaya Hospital

Ampang Hospital

H Selayang



Rural Health Services

u Rural Health Unit § Smallest unit in a district headed by a

physician providing basic health services to the population

§ (WHO)


Three Tier System (1957 – 1973)

MCQ

MHC

HSC

(Coverage: 50,000 people)



TWO TIER SYSTEM

KD

HC

(15,000- 20,000 People)


Primary Care Facilities in Malaysia


Modern Health Centre in

Malaysia


PHC in Other Developing

Countries: Vanuatu


Th

ree

Pill

ars

PUBLIC

•  Ministry of Health

•  Ministry of Education

•  Ministry of Defense

•  Local Authorities

PRIVATE FOR

PROFIT

PRIVATE NOT-FOR-

PROFIT

• Private Hospitals

• Private Clinics • Pharmacies • Laboratories • Hospice • Nursing Homes

• Cancer Care NGOs

• Care for HIV/AIDS

• Palliative Care


Health Services u Primary Health Care Services § Health Centres for MCH § Outpatient Services (GP Clinics); 65% Ambulatory

Contact with Private GPs

u Secondary and Tertiary Care § Public Hospitals (75% of In-patient Beds) § Private Hospitals (25% of In-patients Beds)

u Hospice and Nursing Homes § Private-For-Profit § NGOs


Malaysian Health System: “Important Questions”

u What have we done right in our Health System ?



What have we done right? u Priority on Primary Health Care § Health Services § Health Infrastructure

u Block funding by government § Tax-based funding since Independent

u Government plays major role § Ministry of Health as the main agency given almost

all responsibilities

u Development of Local Specialists Training § Support to local universities



Modernisation of Health System


Modernisation of Health System


Life Expectancy



Selected Vital Statistics

1957-2006



Health Indicators: 2000-2013 Indicators 2000 2005 2008 2010 2013 Life Expectancy At Birth (Years)

Male 70.0 70.6 71.6 71.9 72.6 Female 75.1 76.4 76.4 77.0 77.2

Crude Birth Rate (per 1,000 pop) 24.5 21.0 18.4 17.5 17.2

Crude Death Rate (Per 1,000 pop) 4.4 4.5 4.7 4.8 4.7

Infant Mortality Rate (per 1,000 lv. births) 6.6 5.8 6.2 6.8 6.6

Toddler Mortality Rate (per 1,00o toddlers pop) 0.6 0.5 0.4 0.4 0.4

Maternal Mortality Rate (per 100,000 live births)

30 30 27.3 27.0 25.6

Perinatal Mortality Rate (per 1,000 total births) 7.5 6.8 7.3 7.8 7.4

Neonatal Mortality Rate (per 1,000 live births) 3.8 3.8 3.9 4.4 4.0


12/7/16 27

Roles of Private Health Care u Most Primary Health Care Facilities are in private

Sector § Private Clinics – 8,736 (Medical: 6,978; Dental 1,758) § Health Centres – 1,061

u Most In-patient Beds are in Public Sector § Public sector (2014)

• Hospitals : 150 (MOH: 142; Non-MOH: 8) •  Beds : 43,822 (MOH: 40,260: Non-MOH: 3,562)

§ Private Sector (2014) • Hospitals: 214 •  Beds: 14,033



u What is wrong with our current Health System?



What is wrong with our current

Health System?

MHS Governance

Health Infrastructure

Financing

Research and Development

Health Human Resource



Ministry of Health Malaysia

u Main provider of health care services u Responsible for most health policy matters u Main regulator of healthcare services u Very dominant role in Malaysian Health

Care System


Multiple R

oles of MO

H

MOH

Policy Maker

Funder

Regulator

Provider

Education &

Training

R&D



Governance

u Too much power with too much diversified roles

u “Jack of all Trade; Master of None” u Work in Silos § Poor coordination with other ministries § Carry out actions with no expertise § Recent Vape/e-Cigarette issues

u Reactive response and fire fighting rather than proactive § Dengue Epidemic Copyright of ITCC-UKM


Issue of VAPE: MOH vs Ministy of Rural

and Regional Development Vs Ministry of Youth and Sports





Health Infrastructure

u Poor planning in development of health infrastructure

u Building of hospitals based on political and commercial need rather than health needs § Affect in distribution of hospital services

u Poorly planned health facilities § 1 Malaysia Clinic



Malaysia vs OECD

Hospital Beds Per 10,000 Pop (2013)


133

110

91 83

77 73 70 66 65 63 63

58 58 51 50 49 48 48 47 46

39 38 34 34 33 32 31 31 30 29 28 28 28 27 27 26 23 23 22 17 16 15

0

20

40

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80

100

120

140

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and

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Hospital Beds in Malaysia (2009)

State Total Nos of Beds Beds/10,000 Pop MALAYSIA 35,745 17.06 Perlis 404 17.05 Kedah 2,634 13.56 Pulau Pinang 3,913 24.77 Perak 4,387 18.07 Selangor 7,332 14.57 WP Kuala Lumpur 6,875 40.37 Negeri Sembilan 1,964 19.63 Melaka 1,665 21.86 Johor 4,542 13.89 Pahang 2,036 13.42 Terengganu 1,382 13.34 Kelantan 2,541 15.50 Sabah 4,050 12.36 Sarawak 3,861 15.63




Building of Hospitals



Fire at HSA JB




Health Financing Scenario


Source of Funding for Health

u Public (52%) § Taxation

• Direct Taxation (60%) •  Indirect Tax (40%) including GST-Introduce in

April 2015)

u Private (48%) § Out-of-Pocket Payment (39%) § Private Insurance (7%) § Other Private (2%)


Total Health Expenditure

Malaysia (1997-2013)




Reforms in Health Financing System of Malaysia

u High OOP Expenditure and Catastrophic Expenditure u Long Waiting times in public facilities u Shortage of drugs in public faculties esp for CNCD u Brain drain of specialists to private sector u Too much wastages in health spending (eg: Drugs etc u Lack of Quality and Efficiency monitoring

mechanism u Five attempts to Reform since 1985


Health Financing Issues in SEA: Challenges in Achieving UHC. Lancet (2011), 377 : 863-73


Why do we need NHFS? u Low level spending on health care in most less developed countries

u Fragmenta<on in source of funding u Lack of con<nuity of and streamlining of healthcare services

u Poor coordina<on of care provided by public and private providers

u Need to separate payers and providers to promote efficiency



The Stakeholders…….

Public Providers Private

Providers

Consumers

Politicians Trade Unions

Employers

Medical Associations

Ministry of Health

MCOs Private Insurers

Drug Companies


HEALTH FINANCING SCHEME


Why Our Reforms Failed? u Lack of Political Will to pursue the reform u Weakness of Reform Team

§  Technical Capacity of MOH Staff/Silos)

u Lack of Information (Cost/PPM etc) u Fighting over control of the proposed Agency: MOH

vs EPU u Role of Potential losers: Private Insurers u Lack of Transparency and Public Consultation u Loss of public confidence on government to handle

large fund (Cronyism, Corruptions)


Research and Development

in Health u Gross lack of trained researchers u Inadequate and fragmented research funding u National Institute of Health Research

§  Inefficient use of tax-payer money §  Limited output and poor quality research §  Staff not properly trained researchers §  Creates obstacles for researchers in universities §  Lack of outstanding publication records

u Clinical Research Centres § Many hospitals have these centres §  Staff are mainly MOs who are not trained in research



Researchers in Malaysia



Approval Process



“Pakar Perubatan

Penyelidikan”



Health Human Resource u Rural-urban Maldistribution of doctors u Public-private skewness of specialists u Planning for Human Resource in Health u Allied health and Support staff u Role of MOH in Specialist Training u Pay-For-Performance



Specialists Training in

Malaysia: Role of MOH u Role of Universities § Local Master Programmes

u Open and Close System § Access to MOH Hospitals for Training

u Creation of Parallel Pathways § Link to training programme overseas/off-shore/

Exported Programme



Parallel Pathway to Train Specialists: What is the Impact on Local

Universities?



Malaysian Budget

u 2017 § Total Budget: 260.8 billion RM § Operations: 214.8 § Development: 46.0 § MOH: 25 billion

u 2016 § Total Budget: 267.2 billion RM § Operations: 215.2 § Development: 52.0 § MOH: 23 billion



For Doctors

u Introduction of Gred 56 § Between 54 and Jusa C § To reduce out flow of doctors and dentists to

private sector u Contract Appointment § 2600 Doctors and Dentist to be appointed on

contract basis for housemenship


Gred 56 For Doctors & Dentists





u What should we do now to enhance our Health System?



Proposed Solutions

SOLUTIONS Decentralisation

Higher Priority on Prevention

Active R&D in Health

Social Health Insurance

Enhance Efficiency

Effective Human

Resource Planning


Decentralisation of Health

Services u What is Decentralisation: § “the transfer of authority and responsibility for

public functions from the central government to intermediate and local governments or quasi-independent government organizations and/or the private sector” “ World Bank”

§ is a complex multifaceted concept.



Benefits of

Decentralisation u  A more rational and unified health service that caters to local

preferences u  Improved implementation of health programs u  Decrease in duplication of services as the target populations are more

specifically defined u  Reduction of inequalities between rural and urban areas u  Cost containment from moving to streamlined targeted programs u  Greater community financing and involvement of local communities u  Greater integration of activities of different public and private agencies u  Improved intersectoral coordination, particularly in local government

and rural development activities.




Services in Malaysia u Transfer of ownership of hospitals and

clinic to Regional Health Authorities (RHA) u Combine State Health and Medical Services

Departments as fully-functioning RHA Greater autonomy given to hospitals to provide services

u RHA given full responsibility to plan, deliver and monitor health services




Services in Malaysia u Limited number of hospitals owned and

maintain by MOH directly § National Referral Centre § Specialised Hospitals

• National Cancer Hospitals • Mental Institutions • Respiratory Centre • Hospital for Infectious Disease



Transform Role of MOH u Development of Health Policy u Health Planning and Development u Regulation and Enforcement § Licensing and accreditation of hospitals and

clinics § Monitor private providers

u Minor role as Service providers u Health Promotion and Preventive Services



Transform Role of MOH u Enhance role of MOH in Monitoring and

Evaluation § Benchmarking of Hospitals § Set and Monitor KPI

u Health Management Information System § Systematic collection of Health Information § More detail and high quality data to support

strategic decision making § High quality data analysis



Multiple R

oles of MO

H

MOH

Policy Maker

Funder

Regulator

Provider

Education &

Training

R&D



Transformed R

oles of MO

H

MOH

Health Policy

Monitoring and

Evaluation Service Provider



Proposed Solutions





Improve Efficiency

Effective Human

Resource Planning


Priority on Prevention and

Promotion u Higher spending on Preventive and Promotive

Services u Empower community and Local Authorities u Employ more innovative approach in Prevention u Focus on Primary and Secondary Prevention u Trained more health workers on Prevention and

Promotion § Trained more Public Health Medicine Specialists


Proposed Solutions





Enhance Efficiency

Effective Human

Resource Planning


Research and Development u Establish National Research Council (Korean

Model) u Collate all funding resources under NRC u Research funding on competitive basis u Stop block research funding directly to

specific agencies or ministries u Assess contribution and productivity of NIH

in MOH u Enhance role of universities in R&D Copyright of ITCC-UKM


Proposed Solutions





Improve Efficiency

Effective Human

Resource Planning


Health Financing System u Establish National Health Fund based on SHI

concept outside MOH u Coordinate contributions from public and private

sector u Introduce Provider and Purchase Split u Set-up Multiple agencies to process payment and

claims from providers u Use Strategic Purchasing Methods (Prospective

payment: Capitation and Casemix)



NHFS Implemen<ng Agency

u Set up by legal provision u Public non-‐profit organisa<on u Responsible for All aspects of Policy Development

u With Strong Link and control of Cabinet u Monitors the implementa<on of HFM u Appoint agent to operate the HFM




Voluntary Health Insurance u Potential Strengths § More acceptable to population than private-for-

profit health insurance § Easier to set-up than Social Health Insurance § More freedom of choice to enrollees § Government in control since the entity is under

MOH § Benefit package might be the same as present § Fund may be injected by government


Voluntary Health Insurance u Weakness and Issues § Prone to adverse selection (the sick and high

risk will be more attractive to join) § Limited risk pooling and risk sharing § Premium may be too high without government

subsidy § Provider payment method must be carefully

design to promote efficiency § Providers have to enticed to join the scheme


The Hybrid Model…


• Mandatory • Working population

• Formal Sector & Informal Sector

•  Curative Care

Taxation

• Poor and Unemployed • Preventive and Promotive

Services

Private Insurance

•  The Rich •  Top-up from Basic

Benefit Package





Proposed Solutions





Improve Efficiency

Effective Human

Resource Planning


Health Technology

Assessment u Establish a dedicated independent agency on

HTA u Conduct HTA activities covering new and existing

technologies in public and private health sector u Source staff from universities with proper skills in

HTA u Strict use of Economic Evaluation in decision

making: (CE Threshold < 3 GDP) u HTA Report should be taken on board by

implementing agency



Proposed Solutions





Enhance Efficiency

Effective Human

Resource Planning


Human Resource For Health u Give priority to Local Specialists

Programme u Reduce the number of Medical Schools u Establish more Faculty of Public Health/

School of Public Health u Start undergraduate Training in Public

Health u Use innovative approach in HRM


Faculty of Public Health, Kuwait

University


Conclusion u Malaysian Health System has undergone

series of gradual development since pre-independent era

u  Priority to primary health care and rural development has benefitted most Malaysian

u MHS need to be transformed to provide effective, efficient, equitable and innovative services to the Malaysian population

u Budget 2017 posed major challenges to MHS Copyright of ITCC-UKM


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Malaysian Health System: Current Development, Budget 2017 and Future Challenges

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