Download - Maimunah A.Hamid - 1care1aim
1CARE 1AIM: Evidence to Policy
Dato’ Dr. Maimunah Abdul HamidDeputy Director-General of Health
(Research & Technical Support)
Ministry of Health, Malaysia
5th National Conference for Clinical Research
(NCCR 2011)
23 June 2011
The Sunway Convention Centre, Selangor
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Presentation Outline
• Translating policy directions into value-added research
• Evidence-based policy-making for 1Care
• 1Care Concept
• Evidence to support the 1Care blueprint development
• Evidence needs to ensure evidence-based policies & tracking 1Care targets
• Institutional strengthening for research
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Translating Government Policy Directions into Value-
added Research for 1Care
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Malaysians must be prepared to………. pay more …. health and education…… a scheme ….. quality service. On a review of the health care system, Najib and the Government was considering on a sustainable basis, amid increasing costs and demands.
“The question now is whether we can continue with the present situation or have some sort of scheme.” Najib said adding that he would explain more about the health care system review soon.
“AMANAT” YAB PM in 2005
“Gear up for less subsidy”, saysNajib. (Sunday Star, 6 March ‘05)
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Evidence-based Policy-making for transformation
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Discrepancy in Health Outcomes
by Geographical Location
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Health Indicators :Prevalence by geographical location
%
Urban Rural
History of recent illness 22.4 25.5
Incidence of acute diarrhoea 4.7 5.5
Diabetes Mellitus 12.2 10.6
Hypertension 29.3 36.9
Smoking among adolescence 2.3 4.9
Source: National Health and Morbidity Survey (NHMS) III, 2006
Public & Private Sector Resources and
Workload (2008)
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Source: Health Informatics Center (HIC),MOH
13.54
12081
2199310
41249
143
38.4
802
16.68
10006
754378
11689
209
62.65
6371
0% 20% 40% 60% 80% 100%
Health Expenditure (RM billion) (2007)
Doctors (excl. Houseman)
Admissions
Hospital Beds
No. of Hospitals
Outpatient visits (m)
Health clinics (with doctors)
Public Private
10
11%
38%
41%
78%
74%
55%
45%
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In absence of health financing reform, health system likely to become increasingly privatized…both in funding and service delivery……
In the future with no restructuring of the health system…..
Health expenditures per capita, 2009 prices
0
200
400
600
800
1000
1200
1400
1600
1800
2000
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
GGHE pc PvtHE pc
2004 2009 2018
GGHE 50% 45% 35%
PvtHE 50% 55% 65%
-PvtOOP 40% 47%
-PvtOther 15% 17%Source: Dr Christopher James, WHO WPRO – Projections from MNHA data8
1Care Concept
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1Care Concept
1Care is the restructured integrated
health system that is responsiveand provides choice of quality
health care, ensuring universal coverage for the health care needs
of the population based on
solidarity and equity
1Care Concept
Receive
treatment
Home
Patient
PHCPPublic Private
Admit
ReferredHospital
(Public or
Private)
MOH Additional services
(Out of pocket or private health insurance)
Regional Health
Authority
PHCE PHCE
PHCE
MHDS
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� Streamlined MOH → focused on governance, stewardship & specific public health services, training & research
� Autonomous Malaysian Healthcare Delivery System (MHDS)- integrated public & private sector providers. Emphasis on primary health care. Gatekeeper to higher levels of care
� Publicly managed health fund - combination of general government revenue & social health insurance (SHI), & may be 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
� Government commits to higher levels of spending for healthcare
� People commit to increased cost sharing through pooling of funds and cross-subsidy 12
Features of 1Care
Presentations to YAB PM & Economic Council
• 11 August 2009 - 1Care for 1Malaysia concept
• Follow-up - 22 March 2010, MOH presented research information requested by the Prime Minister and EC:
i. Financial projection of health spending
- in collaboration with Dr Christopher James, Health Economist, WHO
- projections by Bank Negara Malaysia for comparison
ii. Focus Group Discussion with various stakeholders
iii. Impact Assessment
- in collaboration with Prof Soonman Kwon, Seoul National University
- local consultant - Chang Yii Tan, PE research
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No Change and 1Care Reform:
Total Expenditure on Health (TEH)
2009 base year
Summary of Financial Projections
1. No Change
– Health system likely to be increasingly dichotomous– Private health expenditure will rise faster than public
expenditure – Private spending is mainly from out-of-pocket payment →
greater inequity & financial risk to the people and further erosion of the public health system
2. 1Care Reform
– Can contain growth of total health expenditure based on public sector management and prudency
– Savings are more in private spending
– Shortfall in SHI contribution due to health expenditure growing faster than wages
– Government portion of health expenditure will be higher
1516
Gen Tax 44%
Socso&
EPF, 0.4%
OOP40%
PvtCorp & Others
7%
Gen Tax 35%
Socso & EPF, 0.0
0%
OOP 48%
PHI, 9%
PvtCorp
& Others
8%
Gen Tax Public Health &
others 17%
SHI
Gen Tax37%
SHI - Pvt
contribution 34%
Pvt. Spending
11%
Current system (2009)
No Change (2018)
1Care(2018)
PHI
7%
Financial Reforms
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• General consensus among funders, users & providers - concept and proposal was favorable
• Most stakeholders were in favour of the delivery concept
• Funders & users were concerned about having to pay
Focus Group Discussions with
Stakeholders - FINDINGS
Impact Analysis
A) Assessing impact on the Population
• Overall ability to pay
• Willingness to pay
• Un-insured population
• Informal sector
• Immigrant population
B) Assessing impact on the Economy
• Workforce mobility
• Labour market• Consumption
• Government Finance
• Cost of Institutional Change
• Private Health Insurance
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C) Assessing impact on the Health System• Health Care Utilisation
• Quality of Care and Health
Outcomes
• Health Care Cost
• Equity in Access to Health Services
• Impact on Providers
• Impact on Medical Tourism
Evidence to support the 1Care blueprint development
•Technical Working Groups (TWGs)
• Evidence & data
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Blueprint Development : Technical
Working Groups (TWGs)
1. Primary Health Care
2. Secondary & Tertiary Care
3. Health Financing
4. Governance & Stewardship
5. Legislation, Regulation & Enforcement
6. Human Resource
7. ICT
8. Public Health
9. Oral Health
10. Pharmaceutical Services
Additional group – Strategic Communication 20
On-going research to support blueprint development
7 research areas identified since 2008 – only 1 pending, 1 done
1. Health Facility & Services Survey & Population profiling: Mapping health facilities & services against health care needs for strategic policy development
2. Health Care Demand Analysis: Utilisation & equity analysis, models & policy
simulation for 1Care
3. Cost Analysis: unit costing for out-patient & ambulatory services in public hospitals
4. Analysis of Financial Arrangements & Expenditures: in public
& private sectors
5. Community Perception: on health care delivery systems
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Evidence needs to ensure evidence-
based policies& tracking 1Care targets:monitoring & evaluation
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Targets of 1Care for 1Malaysia
• Universal coverage
• Integrated health care delivery system
• Affordable & sustainable health care
• Equitable (access & financing), efficient, higherquality care & better health outcomes
• Effective safety net
• Responsive health care system
• Client satisfaction
• Personalised care
• Reduce brain-drain
Sources of data
Resource
Inputs
Care
Processes
Service
Outputs
Patient or
organisation
level research
• Financing
• Manpower
• Facilities
• Drugs
• Devices
• Diagnosis
• Therapy
• Clinical services
• Procedures
• Out-patients
• In-patients
• Individual : clinical outcome
1. Intermediate (eg. BP control)
2. Ultimate (eg Mortality, QOL, Rehabilitation)
• Centre level performance
1. Effectiveness
2. Equity
3. Efficiency
4. Responsiveness
Population
level
research
• Disease burden incidence & prevalence
• Perception on healthcare system
• Utilisation on healthcare system (incl financial arrangement)
Healthcare System level
(public and private)
Where are the data?
NHMS= National Health Morbidity Surveys; BOD = burden of disease report; MNHA=Malaysian National Health Account;
PR =Patient registries; HSI =Healthcare statistics initiatives (Drugs, Device/Med. Technology, Healthcare Workforce &
Facilities surveys); HRMIS= Human Resource Management Information System, HIC =Health Informatics Center , CD
=Communicable disease, NCD =Non communicable diseasesModified from Lim TO, 2007
Including M&E
Using Research Evidence to Improve
Health System Performance
– E.g. from NHS, UK
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DR FOSTER INTELLIGENCE, Imperial College
Dr Foster Report Card Dr Foster Report Card
Developing Evidence-based Clinical
Practice Guideline
30
30
65
45
6266
7278
45
57
93
70
57
0
25
50
75
100
AU
S
CA
N
FR
GE
R
NE
TH
NZ
NO
R
SW
E
SW
IZ UK
US
Regional Comparative Analysis : Access to Doctor or Nurse When Sick or Needed Care
Percent*
14
33
17 16
5 5
28 25
28
19
AU
S
CA
N
FR
GE
R
NE
TH
NZ
NO
R
SW
E
SW
IZ UK
US
Same- or next-day appointment
Waited six days or more
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
* Base: Answered question.
31
33
20
34 33
5246
3329
44
26
34
0
25
50
75
AUS
CAN FR
GER
NETH N
Z
NO
RSW
E
SWIZ U
KUS
Percent
Regional Comparative Analysis :Wait Time in Emergency Room Before Being Treated
16
31
17
4 3
12 11
20
6 4
13
AUS
CAN FR
GER
NETH NZ
NO
RSW
E
SWIZ U
KUS
Less than 30 minutes Four hours or more
Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.
Base: Used ER in past two years.
Institutional strengthening for research
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Why health research system needs to
transform?
• To contribute towards the achievement for Malaysia to be a high income nation
• To better support MOH’s new role in 1Care
• Breakdown walls to
– enhance function & roles of research institutions
– improve efficiency & reducing duplication of research activities
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6 NIH (National Institutes of Health Research)
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Research Excellence - the Vision
• Leaders in niche research areas
- Tract record in publications
- Opinion leaders
- Attract external funding
- Attract internal collaboration
• Improvements in policy & practice– patients care
– patients outcome
• Recognition
– Earn major awards
– Fellowships of prestigious academies & collages
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What shall we do?
1. Improving governance
– Strengthening research governance
2. Improving capacity & capability of human resource
– Leadership
– Attracting & retaining quality researchers
– Defined career structure (entry as trainee, researcher & senior researcher)
3. Realigning & consolidating current roles
– More focused
– Avoid duplication & improve efficiency
– Better synergy
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What shall we do?
4. Optimising the use of scarce research expertise & other resources
– Sharing of physical & human resources
5. Improving funding
– Generating funds
6. Adopting newer roles
– Broker (searching for external funds & outsourcing of research)
– Marketing of services & products
7. Application of advance technology37
our dream:1NIH
Centre for Information
Technology
(incl clinical support system)
Office of Communications and Public Liaison
Office of International Collaboration
Office of Research Ethics and Policy
Office of Program Coordination and Strategic
Initiatives
MOH Scientific Committee for
Medical Research
Office of the NIH Director
Office of Administrative
Management:
General Administration
Human Resource
Finance & Procurement
Facility Management
IMR
MOH
Centre for Biostatistics
Office of Research & Technical Services
Office of Research Management, Evaluation &
Technology Transfer & commercialization
CRCIHM IKU IHSR IHBR
Data Warehouse
Scientific Advisory Committee
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our dream
The Proposed 1NIH must be BETTER than current model
• Strengths of current system will be preserved
• Stronger supportive role
• Separation of administrative & technicalfunctions
• Better integration of research activities
• More responsive to MOH needs & expectations through increased autonomy
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our dream: 1NIH Complex Artist’s impression
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our AIM: Evidence to Policy & PracticeWE CAN make better contribution to health
• Better interventions
• Informing decision & policy making
• Internalisation by individuals -
changing behaviours &
empowering people
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THANK YOU
Julio FrenkFormer Mexican
Minister of Health