MOH Presentation that has detailed outline of 1Care

1. MALAYSIAN HEALTHCARE
SYSTEM
TOWARDS ACHIEVING BETTER HEALTH
CARE FOR MALAYSIA
Dr. Abd. Rahim bin Mohamad
Planning and Development
Putrajaya 28 September 2010

2. Welcome
Selamat Datang,
Salam Eidil Fitri
 Consultants- lecturers
 Paticipants
• Engineers
• Architects
• Doctors- consultants
• Medical Planners
• Managers
2

3. Presentation Outline
 Ministry of Health
 Vision & Mission & Challenges
 Problem Statement & Issues
 Current Health System
 Transforming the Nation
 The Proposed 1Care Model for Malaysia
 Phases of Development & Financing
 Implications
 RMK-10 Strategic Plan
 Conclusion 3

4. MINISTRY OF HEALTH
Other Govt
Agency
University,
MOE, Youth &
International Sports
WHO,
UNICEF,
Private Sector
UNDP
MOH GPs, Private
Hospitals,
TCM,
Consumers
NGO
Elderly,
Youth, MMA,
PPIM,MOPI,
Children
4

5. MINISTRY OF HEALTH
 Technical Ministry
 Punctuality
 Fast Services
 Evidenced based
 Caring
 Professionalism Corporate Culture
 Teamwork
5

6. Vision & Mission
Vision
 A nation working together for better health
Mission
 The mission of the Ministry of Health is to lead and
work in partnership:
i. to facilitate and support the people to:
• attain fully their potential in health
• appreciate health as a valuable asset
• take individual responsibility and positive action
for their health
6

7. ii. to ensure a high quality health system that is:
• customer centred
• equitable
• affordable
• efficient
• technologically appropriate
• environmentally adaptable
• innovative
7

8. CHALLENGE
In order to achieve Vision 2020, Malaysia needs
to become a country of high income economy.
To achieve the lowest limit for a high income
nation, Malaysia has to make at least 5.5%
yearly growth
8

9. 9

10. PROBLEM STATEMENTS
 Issues raised concerning public medical
services
• Long waiting time
• Postponed cases
• Overworked staff in 3rd class wards –
impersonal…..
• Lack of choice
• Inadequate amenities
 Issues raised concerning private sector
• Exorbitant charges
• Increasing private insurance premium
• Appropriateness of care vs. overservicing

11. PROBLEM STATEMENTS 2
 National Health Account Study 2006
• Out-of-pocket (OOP) spending in Malaysia is high (40% of THE)
• RM 9805 million
• OOP spending in developed countries is low <20%
 Equity
• High cost private healthcare– available only to those who can afford,
insured or covered by employer
• Fairness in financing – high OOP payment (inequitable financing and
can lead to impoverishment due to catastrophic health expenditure)
 Economics
• More efficient use of resources (especially HR)

12. CURRENT ISSUES-1
1. Highly subsidised services & overdependence
on government health facilities (also
patronised by those who can afford)
 Heavy workload
 Long waiting time
2. Inadequate integration in health, especially
between public & private sectors
 “Brain drain” to private sector – non-optimal resource use
 Need for better regulation of private healthcare providers
 Fragmented care and clinical record
12

13. CURRENT ISSUES-2
3. Rising healthcare expenditure
• rising demand and expectations
• expensive high tech medicine/equipments
4. “Gaps” in present healthcare delivery system
eg. Equity, efficiency, accessibility, quality of
service.
5. Changing demographic &
epidemiological patterns
 Increase in the ageing population
 Increase in chronic diseases
13

14. CURRENT ISSUES-3
6. Increasing healthcare charges in private sector
 Greater inequity & public outcry if not controlled
 Increasing trend of private health expenditure
(esp. Out-of-pocket expenditure – financial risk upon
unexpected health events)
 ‘Supplier-induced demand’
 Equity in access to private sector
 Physical : Concentrated in urban areas
 Financial : Access to private services is mainly for those who
can afford esp. inpatient care
14

15. Current Functions of MOH
Within the dual health care system, MOH is Funder,
Provider and Regulator
 Health Policies & Planning  Primary Care Services
 Public Health Activities • Out-patient services
• Communicable Disease • Maternal & Child Health
• Non-communicable Disease
• Health Education
• Home Visits & School Health
 Regulation & Enforcement
 Secondary & Tertiary Services
• Personal care
• In-patient services
• Public Health • Specialist care
• Pharmacy  Pharmaceutical Services
• Technology
 Oral Health Services
• Medical Devices
 Imaging and Diagnostics
 Monitoring & Evaluation
• Quality Assurance  Laboratory Services
• Health Technology Assessment  Telehealth & Teleprimary care
• Patient Safety  Health Information Management
• Guidelines and Standards
 Training
 Research & Development

16. Basic Health Services
Number Beds
 Hospitals 130 33,083
 Special Medical 6 4,974
Institutions(SMI)
 Special Institutions 6 (PDN,PHLab)
 Non –MOH Hosp 8 3,523
 Private hospitals 209 12,216
 Private maternity home 21 102
 Private Nursing Home 12 273
Health Facts 2009

17. Basic Health Services
Number
 Health Clinic(KK) 808
 Community Clinic(KD) 1,920
 Maternal &Child Clinic 90
 Mobile Health Clinic 196
 KKM Dental Clinic 1,724 (2,952 dental chairs)
 KKM Mobile Dental Clinic 560 (1,392 dental chairs)
 Private GPs 6,307
 Private Dental Clinics 1,484
Health Facts 2009

18. OPD & Hosp.Admissions(1997-2009)
* Excludes 9.6m Dental cases& 12,316,350 MCH attendances

19. Public & Private Sector
Resources and Workload (2008)
11%
38%
41%
78%
74%
55%
45%
Source: Health Informatics Center (HIC),MOH
19

20. Public Private Expenditure on Health,
1997-2007 (2007 RM Value)
Source : MNHA (2007)
2.6
18,000 2.5 2.4 2.4
2.3
2.1 2.1
2.1
1.7 1.8 2.1 2.2 2.0
1.6
16,000 1.5 1.9 1.9 16,682
1.6 1.7
1.5 1.6 1.6
1.5
14,360
1.0
14,000 13,034 13,546
0.0
Percentage (%)
12,067
12,000
RM million
11,558 11,542
11,740
10,271
-1.0
10,000
9,083 10,079
8,727
-2.0
8,000
7,320
6,351 7,208
6,000 5,806 6,571 6,824 -3.0
5,616
5,658 5,970
5,538
4,000 -4.0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
Year
20
PUBLIC (RM million) real RM2007 base PRIVATE Public as % GDP Private as % GDP

21. Ratio of Out-of-Pocket (OOP), Public &
Private Expenditures
100%
90% 18.6 23.0
32.0 34.5 32.3 Gen Gov
1.3
80% 44.2 Revenue
14.5 Social
70% 17.1
7.5 Security
60% 1.8 0.7
4.5 0.4 20.8 23.3 External
3.3 7.2 0.1 25.6
50% Resources
7.7 4.1 0.4 Other
0.0 4.0 Other
40% 12.7 3.7 Private
Private
(Employers)
17.5
30% 56.3 51.4 Private
Private
21.6
40.5 Pooled
Insurance
20%
30.2 Private OOP
22.5
10% 14.5
0%
MALAYSIA
Low Lower Malaysia
(2006) Upper High GLOBAL
Income middle middle Income
21
Income Income Source: World Bank, 2005

22. Total Expenditure on Health (TEH)
as Percentage of GDP (2005)
TEH as % of GDP, 2005
12.0
11.2
10.0
8.6
8.0
6.6
6.0
4.8 4.7
4.2 4.2
4.0
2.0
0.0
Low Income Lower middle Income Malaysia Malaysia (2007) Upper middle Income High Income GLOBAL 22
Source : World Bank, 2005

23. TRANSFORMING THE NATION
23

24. Transforming the Na>on
MALAYSIA
People First, Performance Now
Healthcare Transformation
Government Economic CARE FOR MALAYSIA
Transforma>on Transforma>on
Programme Program
CARE FOR MALAYSIA
(GTP)
(ETP)
• effec>ve delivery of • New Economic Model Phase 4
government services – a high income, Phase 1 Phase 2 Phase 3 Full
inclusive and Strengthening of Public PHC reform reform
sustainable na>on the current Facility funded
funded
public system autonomy through GT
funded through
through GT & SHI
GT
10th MP + 11th MP

25. Aligning Our Health System To
Our Country’s Aspirations
New Economic Model
to be achieved through Economic Transformation Programme
(ETP) will propel Malaysia to a high income nation with
inclusiveness and sustainability
8 Strategic reform initiatives:
1. Re-energising the Private sector
2. Developing quality workforce and reducing dependency on foreign
labour
3. Creating a competitive domestic economy
4. Strengthening of the public sector
5. Transparent and market friendly affirmative action
6. Building the knowledge base infrastructure
7. Enhancing the sources of growth
25
8. Ensuring sustainability of growth

26. PROPOSED MODEL
for MALAYSIA
26

27. 1Care Concept
 1Care is the restructured integrated
health system that is responsive and
provides choice of quality health care,
ensuring universal coverage for the
health care needs of the population
based on solidarity and equity
27

28. Targets of 1Care
 Universal coverage
 Integrated health care delivery system
 Affordable & sustainable health care
 Equitable (access & financing), efficient, higher
quality care & better health outcomes
 Effective safety net
 Responsive health care system
 Client satisfaction
 Personalised care
 Reduce brain-drain 28

29. Features of 1Care
 Streamlined MOH → focused on governance, stewardship
and specific public health services, training and research
 Autonomous Malaysian Healthcare Delivery System
(MHDS)- integrated public and private sector providers.
People are registered with particular primary health care
providers (PHCP) - gatekeeper to higher levels of care
 Publicly managed health fund - combination of general
taxation and social health insurance (SHI), and tempered by
minimal co-payments at point of seeking care
 Single payer system, the National Health Financing
Authority (NHFA) – set-up on a not-for-profit basis under the
MOH
29

30. Features of 1Care
 Government commits to higher levels of spending for
healthcare
 People commit to increased cost sharing through pooling of
funds and cross-subsidy
30

31. CHANGES TO THE CURRENT FUNCTIONS OF THE MINISTRY OF HEALTH (MOH)
WITH THE PROPOSED RESTRUCTURING
Professional Bodies
-MMC Independent bodies
-MDC -Drug Regulatory Authority (DRA)
-Pharmacy Board -Health Technology Assessment (HTA)
- Others -Medical Research Council (MRC)
-Patience Safety Council
-Medical Device Bureau
-National Service Framework (NSF) (Quality)
MOH -National Health Promotion Board
NHFA - Food Safety Authority
- Others
POLICY REGULATION & TRAINING RESEARCH
MHDS
PERSONAL
MAKING ENFORCEMENT
CARE
PUBLIC MONITORING &
HEALTH EVALUATION
- Disease -Basic
Control -Post-Basic
- Patient Safety Enforcement Primary Hospital
- HIC - Services Legislation
- Food
- MNHA
- Research Regional Regional
Safety &
- Surveillance Authority Authority
Quality
- H20 Quality - TCM - Professionals
- TCM - Human - Allied Health
- Health Resources - Nursing
Education - Drugs Development
- Quality - Finance PHCT PHCT PHCT
- HTA - Infrastructure &
Equipment
- HTA
- Quality
- ICT

32. Scope of Autonomy
for Independent MOH-owned bodies
 Not-for-profit
 Independent management board
 Self accounting – manages own budget
 Able to hire and fire
 Flexibility to engage and remunerate staff
based on capability and performance
 Accountable to MOH
32

33. Primary Health Care
Primary Health Care
 Thrust of health care services - strong focus on
promotive-preventive care & early intervention
 Primary Health Care Providers (PHCP):
• PHCP are independent contractors
• Family doctor & gatekeeper  referral system
 Register entire population and PHCP
 Dispensing of drugs by pharmacies
 Financing through case-mix adjustments
• Payment by capitation with additional incentives
33

34. Primary Health Care Provider
• PHCPs are led by Family Medicine Specialists (FMS)
• The FMS is registered with the MMC and the National
Specialist Register
• Secondary care specialist are not registered as PHCPs
• Conversion of GPs to FMS
• Accreditation of facilities, credentialing and privileging
of PHCP will be done
34

35. Hospital Services
 Autonomous hospital management
 Patients referred by PHCP
 Financing through casemix
adjustments
• Global budget for public
hospitals
• Case-based payment for
private hospitals
35

36. Human Resource
• Integration of public and private health care providers
• Gaining of number & skills through integration
• Harmonise / equalise remuneration for public and private
• Pay for performance
- Incentives are being considered to promote performance
- Incentives for performance over benchmark, people who work in
remote areas
• In a multidisciplinary team, allied health personnel will
carry out more functions, such as:
• Preventive care by nurses
• Triaging, basic treatment e.g. T&S, STO, etc by nurses and
AMOs.

37. FINANCING
37

38. Financing Arrangements
 Combination of financing mechanisms
• Social health insurance (SHI) + General taxation + minimal Co-payments
for a defined Benefits Package
• Pooled as single fund to promote social solidarity and unity as per
1Malaysia concept
 Social Health Insurance contribution – mandatory
• SHI premium – community rated & calculated on sliding scale as
percentage of income
• From employer, employee & government
38

39. Financing Arrangements
 Government’s contribution (from general taxation) covers
• Public health & other MOH activities
• PHC portion of SHI for whole population
• SHI premiums for registered poor, disabled, elderly (60 years &
above), government pensioners & civil servants + 5 dependants
• Higher spending by govt – 2.9% (In 2007 govt spending 2.1%)
39

40. PHASES OF DEVELOPMENT
40

41. Phases of Health Sector Development
Steady State – 1Care for 1Malaysia
Phase
1Care: Full reform funded through GT & SHI 4
1Care: PHC reform funded through GT Phase 3
Phase 2
1Care: Public Facility autonomy funded through GT
1Care: Strengthening of the current public system Phase
1
41

42. Flow of Healthcare Financing
Consolidated
GOVERNMENT Revenue
MA R
N
D E
A Premium National HEALTHCARE RESTRUCTURED
D
T PACKAGE MOH
O Health HOSPITALS & U
Employee R
Employer, Y Insurance CLINICS
C
Self-employed, E
Foreign- NHFA
V
workers O
(Those who can L EXTRA
Savings, PRIVATE
U COVERAGE /
afford) N Out-of-pocket, ADDED SECTOR G
T Private Insurance VALUE A
A
PACKAGES
R
Y
P
S
42

43. PROPOSAL – ROADMAP
Phased implementation with progression onwards
dependant on the fulfillment of several pre-conditions
Horizon One Horizon Two Horizon Three
June 2010 – Dec 2012 Jan 2013 – Dec 2014 2015 onwards
▪ Review outpatient fees to account ▪ Introduce prescription ▪ Introduce co-payment
for inflation charge for OP (flat rate) charges for outpatients
and inpatient
Proposal ▪ Review inpatient ward charges to ▪ Introduce co-payment
▪ Introduce co-payment
account for inflation charges for inpatient charges for medication
▪ Introduce charge for improper use treatment pegged to cost replacing flat rate
of Emergency services (e.g. 10% of cost) ▪ Review current payment
▪ Suggest that move occurs by Jan ▪ Suggest that move occurs ceiling for 3rd class
2011 by mid-2012 (currently RM 500)
▪ Improve existing exemption ▪ Exemption for medical ▪ Exemption for
provisions in Fees Act (e.g. children, poor and special category medical poor and
Safeguards mothers, welfare) individuals identified in special category
▪ Reimbursement for genuine Fees Act individuals identified
Emergency cases in Fees Act
▪ Definition of medical poor,
and strong mechanisms for ▪ Ability to demonstrate
Pre-
▪ Improved collection mechanisms identifying them (e.g. e-Kasih) better service levels
conditions and quality
for starting
to reduce occurrence of bad debt ▪ Ability to demonstrate better
▪ Clear understanding of strengths service levels and quality ▪ Ability to determine
the phase to ▪ Ability to determine true cost true cost of providing
and limitations of current
mitigate of providing services (e.g. services (e.g.
exemption policy, and ways of
risks development of DRG, ACG) Pharmacy
mitigating
▪ Increase in Class 1 and 2 Information System)
beds to increase availability 43

44. ………Phase 4
 Full 1Care model
 Full integration of public and private health sector
including secondary and tertiary care
 Funded through GT and SHI
 NHFA - manages overall health care financing in
close collaboration with MOH and MHDS.
44

45. Caution & Concerns
 Sensitive nature of topic - social service affects everyone
 Involves many stakeholders – effective strategic
communication required
 Scale of change and restructuring requires considerable
financial investment and commitment
 Realistic time frame & phased implementation
- Outline Perspective Plan for the Health Sector
• Beginning with transformation theme -10MP
 Many phases proposed, each overlapping on the other
- Building blocks to lay foundation and pave the way
45

46. IMPLICATIONS
46

47. Benefits to the Nation…1
1. Strengthen National Unity
- 1Malaysia – Social solidarity through SHI contribution
addressing marginalised segments of the population
- 1Care – National health care programme emphasising
the ethical delivery of health care
2. Stimulate Health Care Market
- Increase health care spending in line with upper
middle income status
- Enhance public/private intergration –Increasing
productivity and system responsiveness
47

48. Benefits to the Nation…2
3. Capitalise on liberalisation and global health care
market
- Attract highly skilled health personnel
- Support health care travel
4. Reduce dependence on government
- Decrease leakage of government spending
- Those who can afford will contribute through SHI
- Cross subsidy by the rich to poor, healthy to sick,
economically productive to dependants (1Malaysia)
- Enhance corporate social responsibility through
employer contribution (1Malaysia)
48

49. Benefits to the Nation…3
5. Ensure social safety nets for lower & middle income
- Better financial risk management - Reduce OOP at point
of seeking care by prepayment of services
- Address equity & access of care - Coverage of poor,
disabled & elderly through general taxation
- Lower insurance premium with wider benefits
6. Contain rapid growth in health care cost
- Address market failures of health care system - promote
greater efficiency e.g. reduces duplication, increase
competition
- More public management of health care financing
– better control of health care inflation 49

50. Benefits to the People
 Access to both public & private providers
 Reduced payment at the point of seeking
care
 Care nearer to home
 Increased quality of care & client satisfaction
 Personalised care
 Access for vulnerable group
 Better health outcome
 Higher work productivity
50

51. Benefits to Employer
 Relieve burden to reimburse worker or give loan for
medical spending
 Relieve burden to cover non-work and work related
illnesses (beyond SOCSO)
 Pay low contributions
 Reduce administration to process medical benefits
 Avoid systems in which unnecessary care lead to higher
expenditure e.g. PHI, MCO & Panel doctors
 Healthier workforce and higher productivity
51

52. Benefits to Health Care Providers
 Bridge the gap between remuneration and work
load among health workers in the public and
private sectors.
 Reduce brain-drain
 Re-address distribution of health staffs through
the provision of specific incentives.
 Ensure appropriate competency through training
and credentialling
 Defined standards of care
52

53. A journey of a
thousand miles begins
with a single step. Lao-tzu
Chinese Philosopher
(604 BC - 531 BC)
Full
1Care
Status PHC
Autonomy
Quo Strengthening Reform
53

54. VISION 2020
States that "by the year 2020, Malaysia is to be a united nation
with a confident Malaysian Society infused by strong moral and
ethical values, living in a society that is democratic, liberal and
tolerant, caring, economically just and equitable, progressive
and prosperous, and in full possession of an economy that is
competitive, dynamic, robust and resilient".
54

55. NATIONAL MISSION THRUSTS
 THRUST 1 :To move the economy up the value chain
 THRUST 2 :To raise the capacity for knowledge and
innovation and nurture ‘first class
mentality’
 THRUST 3 : To address persistent socio-economic
inequalities constructively and
productively
 THRUST 4 : To improve the standard and
sustainability of quality of life
 THRUST 5 :To strengthen the institutional and
implementation capacity
55

56. 10MP 6 STRATEGIC DIRECTIONS
HS 1
Competitive HS2
Private Sector as
Productivity &
Engine of Growth
Innovation
HS 6
Government
Through K-Economy
As an Effective
Facilitator
HIGH INCOME
ADVANCED
ECONOMY HS3
Creative & Innovative
HS5 Human Capital
Quality Of Life With 21st Century
Of An Advanced Skill
HS4
Nation Inclusiveness
In Bridging
Development
Gap 56

57. 10MP STRATEGIES FOR KRA 2 :
Ensure Access to Quality Healthcare & Promote Healthy Lifestyle
HS5
Quality HIGH INCOME
Of Life ADVANCED
Of An ECONOMY
Advanced
Nation
KRA 2
Ensure Access To Quality Healthcare & Promote Healthy Lifestyle
OUTCOME
(Ensure provision of and Increase accessibility to Quality health care and
Public recreational and Sports facilities to support Active healthy lifestyle)
STRATEGY 1 STRATEGY 2 STRATEGY 3 STRATEGY 4
Establish a Transform the
Encourage Empower the community to plan
comprehensive health sector to
health awareness or conduct individual wellness
healthcare system increase the efficiency
& healthy lifestyle programme (responsible for own
& recreational & effectiveness of the
activities health)
infrastructure delivery system
57

58. SUMMARY
Transformation Agenda
VISION 2020
NATIONAL MISSION THRUST
2006-2020
THRUST 1 THRUST 2 THRUST 3 THRUST 4 THRUST 5
To move the To raise the capacity To address persistent
socio-economic To improve the To strengthen the
economy up the for knowledge & innovation & inequalities standard & sustainability institutional &
value chain nurture ‘first class mentality’ constructively & of quality of life implementation capacity
productively
Quality of Life of An
10MPSTRATEGIC DIRECTION 5 (HS5)
Advanced Nation
Ensure access to quality
10MP KRA 2 FOR HS5 Healthcare & promote
Healthy lifestyle
10MP OUTCOME FOR HS5 Ensure provision of & Increase accessibility to
Quality health care & Public Recreational &
Sports facilities to support Active healthy
lifestyle
10MP STRATEGIES FOR HS5
Strategy 4
Strategy 1 Strategy 2 Strategy 3
-- Health Sector
58
-- comprehensive -- health awareness & -- Empowering the Community
Transformation
58
healthcare & recreation Healthy lifestyle towards self care (Universal Access)

59. DEVELOPMENT BUDGET
9MP BUDGET  230 B
10MP BUDGET 165 B Development Expenditure
 15 B PFI Facilitation Fund
TOTAL
 50 B PFI 230 B
Ceiling for 2011-2012 (2 year rolling plan)
(RM 75 B for the whole country)
NKRA projects – 21B
Continued 9MP Projects – 40B
New projects & Private Facilitation Fund – 14B
59

60. CONCLUSION
• Challenge is big ahead of us
• Infrastructure development has to be
ready for the new era
• Sharing of ideas would prepare us for
the next step in Rolling Plan 2 in
RMK-10 & RMK-11 before becoming a
developed nation by 2020
60

61. TERIMA KASIH ATAS
PERHATIAN ANDA