1Care for 1Malaysia: RESTRUCTURING THE MALAYSIAN HEALTH SYSTEM Presented at the 10th Malaysia Health Plan Conference by
Dato’ Dr Maimunah bt A Hamid Deputy Director General of Health (Research and Technical Support)
2nd February 2010
1
Presentation Outline • Current Health System & Challenges • Proposed Model for Malaysia – Delivery system & Governance • Primary Health Care • Secondary Care • Human Resource Development
– Financing
• Implications 2
CURRENT HEALTH SYSTEM & CHALLENGES
3
Overview of Current Malaysian Health System
4
Access to Health Providers in Malaysia MOH
Other agencies & Private sector
Rural/Community Clinics 1 : 4,000 population
Others
University Hospitals Estate
Health Clinics/Centres 1 : 20,000 population
GPs
PRIMARY HEALTH CARE
Hospitals without Specialists
Orang Asli Facilities
Hospitals with Specialists
Private Hospitals
Hospitals with Subspecialty
Medical Corps
SECONDARY/TERTIARY CARE
By passing
Public & Private Sector Resources and Workload (2008) 11%
Health clinics (with doctors)
802
6371
38%
Outpatient visits (m)
38.4
62.65
143
209
41%
No. of Hospitals 78%
Hospital Beds
11689
41249 74%
2199310
Admissions
754378
55%
12081
Doctors (excl. Houseman)
10006
45%
13.54
Health Expenditure (RM billion) (2007) Public
Private
0%
20%
16.68 40%
60%
80%
100% 10
Source: Health Informatics Center (HIC),MOH 6
Current Functions of MOH Within the dual health care system, MOH is Funder, Provider and Regulator • •
Health Policies & Planning Regulation & Enforcement – – – – –
•
Monitoring & Evaluation – – – –
• • •
Personal care Public Health Pharmacy Technology Medical Devices Quality Assurance Health Technology Assessment Patient Safety Guidelines and Standards
Training Research & Development Health Information Management
•
Primary Care Services – – – –
•
Secondary & Tertiary Services – –
• • • • • •
Out-patient services Maternal & Child Health Health Education Home Visits & School Health In-patient services Specialist care
Pharmaceutical Services Oral Health Services Imaging and Diagnostics Laboratory Services Telehealth & Teleprimary care Public Health Activities – Communicable Disease – Non-communicable Disease
Current Challenges in Malaysian Health System 1. 2. 3. 4. 5. 6. 7.
Lack of integration Changing trends in disease pattern & socio - demography Greater expectations from public Dependency on govt. subsidised services – Issues of economic inefficiency Limited appraisal & reward systems for performance Conflicts of interest Accessibility & affordability - Discrepancy of health outcomes
8.
9.
Limited coverage of catastrophic illness e.g. haemodialysis, cancer therapy, transplants etc. Private spending for health overtaken public since 2004 8
Public Private Expenditure on Health, 1997-2007 (2007 RM Value) Source : MNHA (2007) 2.5
16,000
1.5 1.5
1.6 1.5
1.6
1.6
2.0
1.9
1.9
16,682
14,360
14,000
RM million
2.6
2.2
1.7
1.6
2.4
2.1
2.1
1.8
1.7
2.3
2.1
2.1
2.4
1.0 13,546
13,034
0.0
12,067
12,000
11,542
11,558 11,740
10,271
-1.0
10,000 9,083
8,727
-2.0
8,000
7,320 7,208
6,351 6,000
10,079
5,806
5,616
6,571
-3.0
6,824
5,970
5,658
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
9 Public as % GDP
Private as % GDP
Percentage (%)
18,000
Ratio of Out-of-Pocket (OOP), Public & Private Expenditures 100% 90%
80% 70% 60%
18.6
23.0
1.3 14.5
7.5 1.8
50%
44.2 0.7
4.5 3.3
0.4 7.2 7.7
20.8 0.1
4.1
12.7
56.3
34.5
32.3
17.1
40% 30%
32.0
51.4
20%
40.5
25.6 0.0
3.7
23.3 0.4
4.0
17.5 21.6
30.2
10%
14.5
22.5
Gen Gov Revenue Social Security External Resources Other Other Private Private (Employers) Private Private Pooled Insurance Private OOP
0%
Low Income
Lower middle Income
MALAYSIA Malaysia (2006)
Upper middle Income
High Income
GLOBAL 10 Source: World Bank, 2005
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 4.2
4.2
4.7
4.0
2.0
0.0
Low Income
Lower middle Income
Malaysia
Malaysia (2007)
Upper middle Income
High Income
GLOBAL
11 Source : World Bank, 2005
Government Spending on Health as % of Total Government Expenditure (2006) Government Spending on Health as % of Total Government Expenditure 25
20
15
7.0%
10
5
Government Spending on Health as % of Total Government Expenditure
0
Source : WHOSIS data 2006
Health expenditures per capita, 2009 prices 2000
In the future with no restructuring of the health system…..
1800 1600 1400 1200 1000 800 600 400 200
20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19
0
GGHE pc
GGHE PvtHE -PvtOOP -PvtOther
PvtHE pc
2004 50% 50%
In absence of health financing reform, health system likely to become increasingly privatized… both in funding and service delivery……
2009 45% 55%
2018 35% 65%
40% 15%
47% 17%
Source: Dr Christopher James, WHO WPRO – Projections from MNHA data
The Combination of Organisational and Financial Reforms A Nation Chooses Depends on What Goals A Nation Wants to Achieve
Aligning Our Health System To Our Country’s Aspirations New Economic Model ? Malaysia Economic Monitor: Repositioning for Growth - 4 Key Elements (World Bank, November 2009) 1.
Specialising the economy - high value-added, innovation-based, strong growth potential, enabling environment internally-competitive appropriate soft and hard infrastructure knowledge economy
2.
Improving the skills of the workforce – specialised and skilled labour moving up the value-chain, social and private returns to education and skills upgrading, increase productivity
3.
Making growth more inclusive – Strong inclusiveness policies, equity, helping household cope with poverty through health care
4.
Bolstering public finances – broaden the country’s narrow revenue base, lessen subsidies, reduce the crowding-out of private initiatives, shift expenditure to areas of specialisation, skills and inclusiveness
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PROPOSED MODEL for MALAYSIA
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1Care Concept
• 1Care is restructured national health system that is responsive and provides choice of quality health care, ensuring universal coverage for health care needs of population based on solidarity and equity
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 18
Features of Proposed Model: BETTER than current system • Strengths of current system will be preserved • Stronger stewardship role for MOH & government • Separation of purchaser-provider functions • 1Care - Integration of health care providers & services
• More responsive to population health needs & expectation through increased autonomy • Payments linked closely to performance of provider 19
DELIVERY SYSTEM & GOVERNANCE
FUNCTIONS WITHIN THE RESTRUCTURED HEALTH SYSTEM Professional Bodies
Independent bodies
-MMC -MDC -Pharmacy Board - Others
NHFA
• GOVERNANCE & STEWARDSHIP • POLICY & STRATEGY FORMULATION • STANDARD SETTING • REGULATION & ENFORCEMENT • MONITORING & EVALUATION • PUBLIC HEALTH • RESEARCH • TRAINING
MOH
-Drug Regulatory Authority (DRA) -Health Technology Assessment (HTA) -Medical Research Council (MRC) -Patience Safety Council -Medical Device Bureau -National Service Framework (NSF) (Quality) -National Health Promotion Board - Food Safety Authority - Others
MHDS SERVICE DELIVERY • PRIMARY CARE • HOSPITAL CARE • OTHER SERVICES
CHANGES TO CURRENT FUNCTIONS OF MOH WITH PROPOSED RESTRUCTURING Professional Bodies -MMC -MDC -Pharmacy Board - Others
Independent bodies
MOH
NHFA
PUBLIC HEALTH
MONITORING & EVALUATION
-Disease Control -Food Safety & Quality -Health Education
-HIC - MNHA - Surveillance - H20 Quality - TCM
-Drugs - Quality - HTA
POLICY MAKING
-Patient Safety - Services - Research - TCM - Human Resources Development - Finance - Infrastructure & Equipment -HTA - Quality - ICT
REGULATION & ENFORCEMENT
-Drug Regulatory Authority (DRA) -Health Technology Assessment (HTA) -Medical Research Council (MRC) -Patience Safety Council -Medical Device Bureau -National Service Framework (NSF) (Quality) -National Health Promotion Board - Food Safety Authority - Others
TRAINING
RESEARCH
-Basic -Post-Basic Enforcement
PERSONAL MHDS CARE
Primary
Legislation
Regional Authority
Hospital Regional Authority
-Professionals - Allied Health -Nursing
PHCT
PHCT
PHCT
Scope of Autonomy for Independent MOH-owned bodies • Not-for-profit
• Accountable to MOH • Independent management board • Self accounting – manages own budget • Able to hire and fire • Flexibility to engage and remunerate staff based on capability and performance 23
SERVICE DELIVERY & PATIENT FLOW Patient
PHCP Public
Additional services (Out of pocket or private health insurance)
Refer Hospital
Private
Receive treatment
Private
Admit
Return to referring PHCP
Home
Public
FUNDING & GOVERNANCE NHFA
MOH
MHDS
Regional Health Authority
PHCT PHCT
PHCT
Outpatient and Hospital care free at point of service Minimal co-payments e.g. for dental & pharmacy
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 to specific PHCP according to location of home/work/schooling
• Dispensing of drugs by independent pharmacies • Payment - capitation with additional incentives – casemix adjustments 26
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 – thru x months training from accredited training centres/providers
• Over time only Primary Health Care Specialists are allowed to open a PHCP practice • Accreditation of facilities, credentialing and privileging of PHCP will be done 27
Hospital Services • Regional arrangement for hospital services & set-up to better serve the needs of local community in each region • Patients referred by PHCP • Autonomous hospital management • Financing through casemix adjustments – ? Global budget for public hospitals – ? Case-based payment for private hospitals
28
Human Resource • Integration of public & private health care providers → increase access for population • Gaining of number & skills through integration • Facilitate providers working in both sectors – suitable arrangements have to be developed • Harmonise/equalise remuneration for public & private • Pay for performance -
Incentives are being considered to promote performance
-
Incentives for performance over benchmark, people who work in remote areas
Role of Allied Health • Utilisation of allied health personnel will reduce cost & support the role of health professionals
• This will contribute towards overcoming the shortage of human resource • In line with 1Malaysia Clinic launched by PM, it is possible for allied health personnel to carry out certain functions, such as: – Preventive care by nurses – Triaging, basic treatment e.g. T&S, STO, etc by nurses & AMOs.
Human Resource: Training •
MOH still determines the human capital needs of the country
•
Within integrated system in-service training has to be planned between public & private facilities
•
? outsource training to institution or teaching facilities
•
? Open system for formal post-graduate training of doctors
- Universities need to review current programme •
Credentialing & Privileging – Independent Body – e.g. National Credentialing Committee (NCC), Academy of Medicine etc.
•
Continuing Professional Development (CPD)
– Current system • fund - health facilities / self funded – Compulsory – minimum CPD points/per year for APC – Use for recertification.
31
FINANCING
32
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
33
A Summary of Ranking of Different Health Financing Methods Equity
Risk Pooling
Reduce Risk Selection
Efficiency*
General Rev
General Rev
General Rev
User Fee, OOP, MSA (Low administrative cost but sometimes hard to collect – so higher cost)
Social Ins
Social Ins
Social Ins
Social Ins
Comm Fin.
Comm Fin
Comm.Fin
Comm. Fin.
Private Ins
Private Ins
Private Ins
Private Ins (High Administrative Cost)
User Fee, OOP, MSA
User Fee, OOP, MSA
---------------
General Rev/ Direct Provision (Inefficient ) – Generally – may not be the case in Malaysia
BEST
WORST
*Efficiency factors include technical efficiency and administrative costs.
Social Health Insurance • SHI is another financing approach for mobilising funds & pooling risks, earmarked tax
• Community-rated, not risk-rated as in private health insurance (PHI) – all are eligible • High levels of cross-subsidization – Rich to poor – Economically productive to dependants – Healthy to ill
• 3 distinct characteristics – Compulsory enrollment, payment of premium. – Benefits eligible for those who contribute only – Benefit Package is predetermined
35
Social Health Insurance Advantages
Disadvantages
• •
•
• •
Pools Risk & Resources Mobilise funds designated for health system - public acceptance Planned prepayment - OOP Equity – payment according to ability to pay – improve equity in access
•
Promote health system development – health information system – rational planning of health services & resources
• •
• •
•
Challenges in coverage of informal sector & determining the poor Need to have a good administrative capacity SHI requires legislation to provide a legal framework for authorising mandatory, earmarked contributions Need accurate estimates of the benefits package & costs PPM that shifts financial risk of provision to the provider, e.g. capitation need to be continuously monitored & evaluated Abuse of SHI fund may be a threat 36
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
• 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 – 2.85% (In 2007 govt spending 2.11%)
37
Main Sources of Health Financing
38
Total Health Expenditures with and without 1Care restructuring Constant 2009 prices (millions)
90,000
80,000
70,000
60,000
50,000
40,000
30,000
2009
2010
2011
2012
No major changes
2013
2014
2015
1Care
2016
2017
2018
IMPLICATIONS
40
Implications of Proposed System • • • • • • • • • •
Public-private integration Stronger governance role in a slimmer MOH Defined practice standards Benefits package Payment by performance Registries for providers and patients Gate-keeping role by primary care providers Autonomous management public healthcare providers Services free at point of care – minimal co-pay Mandatory regular contribution (prepaid) under SHI
• More funding of health with increased coverage 41
Benefits to Individuals • • • • • • • • •
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 with specific PHCP Access for vulnerable group Better health outcome Higher work productivity All (except govt covered groups) will have to pay to be within the system 42
Benefits to Employers • Relieve burden to reimburse worker or give loan for medical spending • Relieve burden to cover work and non-work related illnesses (beyond SOCSO)
• Pay low contributions to cover employee and family • Reduce administration to process medical benefits • Avoid systems in which unnecessary care leads to higher expenditure e.g. PHI, MCO & Panel doctors
• Healthier workforce and higher productivity • All companies have to contribute – ? tax rebate 43
Benefits to Health Care Providers • Bridge the gap between remuneration and work load among health workers in the public and private sectors. • Creates more effective demand for healthcare • Re-address distribution of health staffs through the provision of specific incentives. • Defined standards of care • Ensure appropriate competency through training credentialing and privileging • Reduce brain-drain, increase available pool of providers 44
Benefits to the Nation • Strengthen National Unity - 1Care for 1Malaysia • Ensure social safety nets for lower & middle income - Reduce OOP at point of seeking care - Address equity & access of care - Ties-in with current policies of govt
• Contain rapid growth in health care cost • Stimulate health care market – create more effective demand for health care, multiplier effect
• Capitalise on liberalisation and global health care market • Reduce dependence on government 45
Cautions & Concerns • Manage change effectively
• Need for strategic communication of issues and plan • Longer term planning. • Adequate time for phased implementation including preparation of manpower, ICT & infrastructure
• Increase investments to effect change • Acts and Regulations to enable change • Current economic & global situation may not be an ideal time for change but is an ideal time for planning & preparing the groundwork 46
THANK YOU
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