dr abdul rahim
DESCRIPTION
This MOH presentation proposes the wholesale reform and privatisation of the Malaysian healthcare system, instead of reforming and strengthening the present system.TRANSCRIPT
FUTURE OF HEALTH CARE FINANCING IN MALAYSIA
DR ABD RAHIM MOHAMAD
PLANNING & DEVELOPMENT DIVISION
MINISTRY OF HEALTH
18TH JANUARY 2009
PRESENTATION OUTLINE
Scope of Healthcare Financing Aim Objectives Problem Statements Current Issues Options Principles NHFA Benefit Packages Conclusion
SCOPE OF HEALTHCARE FINANCING
1. Revenue Collection Source of Financing Structure Collection mechanism
2. Pooling of Funds Managed by an intermediary body
3. Purchasing – from health providers
SOURCESSOURCES OF OF FINANCINGFINANCING
e.g. NHI, Govt. e.g. NHI, Govt. budget, etcbudget, etc
INTERMEDIARY INTERMEDIARY BODYBODY
NHFANHFA
GOVERNANCEGOVERNANCE•CORPORATECORPORATE
•CLINICALCLINICAL
PROVIDERPROVIDERPAYMENTPAYMENT
MECHANISMMECHANISM
ESSENTIALHEALTHCARE BENEFITSPACKAGES
HEALTHCARE DELIVERY SYSTEM
NATIONAL HEALTHCARE FINANCING MECHANISM
THE SCOPE / SPECTRUM
PATIENTS /CONSUMERS
CONTRIBUTIONCONTRIBUTION
GOVERNMENT GOVERNMENT BUDGET BUDGET casemixcasemix
global budgetglobal budgetcapitationcapitation
fee-for-fee-for-servicesservices
Aim of Healthcare Financing
Provision of accessible healthcare and peace of mind
Comprehensive healthcare protection Improve health through prevention More choice of service Right mix of financing option to deliver health
care Government will still be main player Complemented by NHI
NHFM
Enhance efficiency & quality
Greater integration in
Health:10 , 20 , 30
Public / privatePrimary care as gatekeeper
Better regulationof health
care providers
Achieve greaterequity & accessibility
Enhance national integration, social solidarity and caring society
NATIONAL HEALTHCARE FINANCING: OBJECTIVES
Mobilize Resources“Risk sharing” &pooling of resources(Community rated NHI System) & manage rateof healthspending
6NOT to change the present system if these goals are not metNOT to change the present system if these goals are not met
WHY DO WE NEED CHANGE
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
adverse selection vs cherry picking Appropriateness of care vs. overservicing
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% Health Expenditure trend in Malaysia
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)
10
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
11
CURRENT ISSUES-2
3. Rising healthcare expenditure • rising demand and expectations• expensive high tech medicine
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
Trend of Total Expenditure on Health (TEH), 1997-2006 (RM, Nominal Value)
8 9
10
12 13
14
19
21 22 24
2.9
3.2 3.2 3.4
3.7 3.8
4.5 4.5
4.2 4.3
-
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
-
5
10
15
20
25
30
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Y2
(% G
DP
)
Y1
(RM
Bill
ion
)
YearTEH TEH as percentage of GDP
1212Source : MNHA
PUBLIC VS PRIVATE
HEALTH EXPENDITURES
NHFS (1984/85)
MNHA (2002)
MNHA (2006)
PUBLIC
PRIVATE
76 %
24%
56%
44%
45.2%
54.8%
Proportion of Public vs Private Sectors Expenditures
NHFS: National Health Financing StudyMNHA: Malaysian National Health Account
Per Capita Spending on Health, 1997-2006 (RM, Nominal Value)
381 406 432501 529 560
756829 826
917
0
100
200
300
400
500
600
700
800
900
1000
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
RM
Year
Per Capita Spending on Health
1414
Operating and Development Expenditure, MOH 1990-2004
-
1,000.0
2,000.0
3,000.0
4,000.0
5,000.0
6,000.0
7,000.0
8,000.0
9,000.0
10,000.0
1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Year
RM
Mill
ion
Operating
Development
Total
Note: Using Current PricesSource: Finance Division, MOH
Source: MNHA Study 2003-2006, Health At A Glance 2007- OECD Indicators
TOTAL HEALTH EXPENDITURE AS PERCENTAGE OF GDP IN SELECTED OECD COUNTIRES AND MALAYSIA,
2005
TOTAL HEALTH EXPENDITURE AS PERCENTAGE OF GDP IN SELECTED OECD COUNTIRES AND MALAYSIA,
2005
16
17
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 areasFinancial : Access to private services is mainly for those who can afford esp. inpatient care
Private Health Expenditure (PHE) (MNHA 2006)
Total PHE: RM 13,393 million OOP: RM 9,804 million (73%)
OOP from 2003 to 2006: rising trend (quantum)
7. Challenges of globalization & liberalization: Cross border flow (human, life-stock, etc)
Transmission of diseases Cross border transactions and practice – ethics,
credentials and quality Foreign workers
Utilizing subsidised services Health insurance coverage not mandated currently
Outsourcing / offshore activities Health tourism – competing with local consumers for
resources
19
CURRENT ISSUES-4
Health Expenditure Trends in Malaysia (MNHA 2006)
Increasing Total Expenditure of Health (TEH)
Plateauing TEH as % of GDP OOP rising Private Expenditure exceeded public
expenditure since 2004
WHERE DO WE GO FROM HERE?
OPTIONS
1. Change present system Introduce NHI through community rating Further integrate public-private health sectors
AND / OR2. Strengthen present system
Improve efficiency and quality of public and private sectors
Further regulate private sector to improve quality and contain cost
Financing Strategy
Introduce a National Health Financing Mechanism & restructuring of MOH hospitals and clinics.
Develop National Health Insurance with government intermediary body (National Health Financing Authority) as a single fund manager.
Superior to existing systemSingle healthcare financing system / single fund manager
(National Health Insurance fund/ Government Revenue)If contribution based (NHI)
Mandatory- those who can afford to pay must pay Government assistance for disadvantaged group.
NHFANot-for-profitGovernment owned accountable to MOH & should not be privatised
Greater equity, access, quality, efficiency & choice Greater integration in healthcare (public-private, primary-secondary) Viable & sustainableViable & sustainable Improvement of health status of populationImprovement of health status of population In line with: In line with:
National solidarity & a caring society Vision for Health & Vision 2020, etc.Vision for Health & Vision 2020, etc.
PROPOSED PRINCIPLES OF HEALTH CARE FINANCING MECHANISM
PROPOSAL:NATIONAL HEALTH FINANCING AUTHORITY (NHFA)
THE GOVERNANCE OF THE NATIONAL HEALTH FUND
NHFA
Government ownedAccountable to MOH
Statutory BodyNot-for-profit
Single fund manager
Not to be privatised
Proposed Functions:1. Policy, research & corporate health planning2. Health benefit packages 3. Assessment of healthcare4. ICT planning & applications5. Utilisation data6. Health financing data 7. Fund
collection/disbursement8. Strategic human resource
planning & training9. Provider
payment/negotiation
PROPOSAL:ESSENTIAL HEALTHCARE PACKAGES (EHP)
SOURCE:NATIONAL
HEALTHINSURANCE
OTHER SOURCES
e.g. PHI, Employer, OOP, etc.
ESSENTIAL HEALTHCARE PACKAGEESSENTIAL HEALTHCARE PACKAGES (EHP)S (EHP) - In line with wellness paradigm- In line with wellness paradigm - Covers - Covers selected selected preventive, promotive, preventive, promotive, curative & rehabilitative servicescurative & rehabilitative services- Available from public & private sectors Available from public & private sectors
NON-ESSENTIAL/ NON-ESSENTIAL/ OPTIONAL HEALTHCARE PACKAGEOPTIONAL HEALTHCARE PACKAGESS- Voluntary/ means tested- Voluntary/ means tested- For optional coverage not covered- For optional coverage not covered in the essential health care packagesin the essential health care packages- Available from public & private sectors- Available from public & private sectors
Taiwan – Wide benefit coverage (includes traditional medicine)Korea – Narrow benefit coverage
NOTE: Need to consider affordability and sustainability in developing EHP
PROPOSAL:- PREMIUM LEVEL & INCENTIVES
AFFORDABLE & ACCEPTABLE PREMIUMAccording to ability to pay (Progressive)
GOVERNMENT ASSISTANCE For the disadvantaged group.
SOURCES OF FINANCING
e.g. NationalHealth Insurance, govt.budget
NATIONALHEALTH
FUND
GOVERNANCEi.e INTER-MEDIARY
BODY(NHFA)
PROVIDERPAYMENT
MECHANISM
ESSENTIALHEALTHCARE BENEFITSPACKAGES
HEALTHCARE DELIVERY SYSTEM
NATIONAL HEALTHCARE FINANCING MECHANISMNATIONAL HEALTHCARE FINANCING MECHANISM
THE SCOPE / SPECTRUMTHE SCOPE / SPECTRUM
FFUUTTUURREE
HHEEAALLTTHH
SSYYSSTTEEMM
Monitoring, Evaluation, Regulation & EnforcementMonitoring, Evaluation, Regulation & Enforcement
PATIENTS /CONSUMERS
MANDATORYCONTRIBUTION
LEVEL &CEILING OF
CONTRIBUTION&
CO-PAYMENT,MEANS TEST
casemixcasemixglobal budgetglobal budget
capitationcapitationfee-for-servicesfee-for-services
Ministry of Health
PROPOSED HEALTHCARE SYSTEM
GovernmentConsolidated Revenue MOHMOH
MANDATORY
VOLUNTARY
National Health Fund
Savings,Out-of-pocket,Private Insurance
NHFA
ESSENTIALHEALTH BENEFITPACKAGES
EXTRACOVERAGE /ADDED VALUE PACKAGES
RESTRUCTU-RED MOHHOSPITALS & CLINICS
PRIVATESECTOR
New New role role
of of MOHMOH
REDUCE
GAPS
Employee Employer,
Self-employed,Foreign-workers
(Those who can afford)
Premium
ROLL-OUT OF NHFM
Recommendations of previous consultants Adopt incremental approach
o E.g. Population coverage (formal vs. Informal sector)o Service coverage (outpatient vs. inpatient)o Accessibility (public vs. private)
Path dependent – while adopting good practices of other countries
Implement certain activities during 9MPo Case-mix
Accuracy of Diagnosis
o Unit costingo Social Advocacy (meeting with stakeholders)
Assurance
Government will still be main source of healthcare fund
Government will subsidise the disadvantaged. MOH will monitor the following:
Access Utilization Quality and safety
Press comments on Proposed Privatisation of IJN by IJN staff
“Hospital staff deny demand for higher pay linked to proposal. Medical consultants at the National Heart Institute (IJN) have reiterated their commitment to serve IJN in its current form”
“However, the perception that the privatisation proposal is in response to demands for higher remunerations by its medical staff is misconceived and must be corrected accordingly to safeguard and preserve the trust placed upon us by our patients”
The Star, 20th December 2008
Press comments by IJN pioneer surgeon
“It (IJN) was never meant to be commercial institute. It was meant to be a centre of research, a premier academic institute.”
“Therefore, I am rather suspicious of the privatisation idea. It is not as if the hospital is not doing well. Ideally, a health institution such as IJN should be physician-led”
Tan Sri Dr. Yahya AwangThe Star, 21st December 2008
CONCLUSION
Implementation of the NHFM should be: Incremental Path Dependent Most appropriate for the country (Creative and
Innovative)
“Innovative thinking in developing the most appropriate financing mechanism (choice and design) best suited for the country”
Diane McIntyre
“Innovative thinking in developing the most appropriate financing mechanism (choice and design) best suited for the country”
Diane McIntyre
If you would like to give input and comments, please visit:
http://malaysianhealthcaresystem.blogspot.com/
If you would like to give input and comments, please visit:
http://malaysianhealthcaresystem.blogspot.com/