Dr Rahim Ministry Of Health
- 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
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- 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