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Public–Private Partnerships in Health in Malaysia:Lessons for Policy ImplementationKai-Lit Phuaa, Sharon Wan-Hui Lingb & Kai-Hong Phuac

a School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway,Malaysiab Monash University Malaysia, Bandar Sunway, Malaysiac Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore,SingaporePublished online: 01 Jul 2014.

To cite this article: Kai-Lit Phua, Sharon Wan-Hui Ling & Kai-Hong Phua (2014) Public–Private Partnerships in Healthin Malaysia: Lessons for Policy Implementation, International Journal of Public Administration, 37:8, 506-513, DOI:10.1080/01900692.2013.865647

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International Journal of Public Administration, 37: 506–513, 2014Copyright © Taylor & Francis Group, LLCISSN: 0190-0692 print / 1532-4265 onlineDOI: 10.1080/01900692.2013.865647

Public–Private Partnerships in Health in Malaysia: Lessons for PolicyImplementation

Kai-Lit PhuaSchool of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia

Sharon Wan-Hui LingMonash University Malaysia, Bandar Sunway, Malaysia

Kai-Hong PhuaLee Kuan Yew School of Public Policy, National University of Singapore, Singapore, Singapore

The government of Malaysia, an early and enthusiastic supporter of the concept of privatizationof public services, can also be considered as being highly supportive of more recent strategiessuch as “public–private partnerships” (PPPs) in the delivery of social services. It establisheda Public–Private Partnership Unit (UKAS) in 2011. This discussion of Malaysia’s experiencewith health care PPPs is based on a literature review. The record is mixed, with successesand failures. Critical factors for success include regulation, transparency, clear policy guid-ance and clarity on operational procedures and responsibilities, proper evaluation mechanisms,sustained financial support, especially for NGO partners, and unwavering commitment frompolicy-makers.

Keywords: public–private partnerships, health care, Malaysia

INTRODUCTION

The government of Malaysia, an early and enthusiastic sup-porter of the concept of privatization of public services(Jomo, 1995), can also be considered as being highly sup-portive of more recent developments such as “public–privatepartnerships” (PPPs) in the delivery of social services. High-level support for the latter is indicated by the establishmentof a Public–Private Partnership Unit (UKAS) in the PrimeMinister’s Department in 2011.

Because of Malaysia’s long experiment with privatizationand the subsequent adoption of the concept of PPP (togetherwith the strategy of utilizing private sector resources in thedelivery of social services such as health care), its experiencecould provide valuable lessons for other nations. This arti-cle aims to look at specific Malaysian PPP “successes” and

Correspondence should be addressed to Kai-Lit Phua, School ofMedicine and Health Sciences, Monash University Malaysia, Jalan LagoonSelatan, Bandar Sunway, 46150 Malaysia. E-mail: phuakl@hotmail.com

“failures” in the area of health care, and the factors leadingto these results.

The term “public–private partnership” has been definedin various ways. For example, the broad definition usedby Hodge and Greve (2009) is “cooperative institutionalarrangements between public and private sector actors”(p. 33). They noted that the term PPP seems to encom-pass five types of arrangements, that is, joint productionand risk sharing; long term infrastructure contracts; publicpolicy networks; civil society and community developmentprojects; and urban renewal and downtown developmentprojects (Hodge & Greve, 2007).

Michael Reich (2002) defines a PPP as involving “at leastone private for-profit organization and at least one not-for-profit or public organization . . . the partners have someshared objectives for the creation of social value, often fordisadvantaged populations . . . (and) the core partners agreeto share both efforts and benefits” (p. 3).

The Organisation for Economic Co-operation andDevelopment (OECD) explicitly excludes nonprofit organi-zations from its definition of PPP. According to the OECD

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PUBLIC–PRIVATE PARTNERSHIPS IN HEALTH IN MALAYSIA 507

(n.d.), a PPP is an arrangement for “delivering and fund-ing public services using a capital asset where project risksare shared between the public and private sector. . . . (andit is) . . . a long term agreement between the governmentand a private partner where the service delivery objectivesof the government are aligned with the profit objectives ofthe private partner” (p. 3).

The World Bank Institute (2012) states that a PPPis essentially an arrangement to “mobilize private sectorresources—technical, managerial, and financial—to deliveressential public services such as infrastructure, healthand education” (“Overviews”), while the World HealthOrganization (WHO) views it as a means to “bring together aset of actors for the common goal of improving the health ofpopulations based on mutually agreed roles and principles”(Kickbusch & Quick, 1998, p. 69). In terms of such partner-ships in the area of health services, Malaysia’s Ministry ofHealth (MOH) does not use the term “public–private partner-ship”; instead, it uses the term “public–private integration” tosignify cooperation between the public and private sectors,and the utilization of private sector resources to bring aboutmore equitable delivery of services.

PPP PERFORMANCE AND FACTORSAFFECTING PERFORMANCE

The evaluation of “success” and “failure” in PPP perfor-mance can be carried out along different dimensions, forexample, financial (such as value-for-money), equity, access,quality, and so forth. There is the possibility that some ofthese dimensions may clash; for example, the promotionof access may increase costs, and greater equity in servicedelivery may affect overall quality.

PPP success or failure may depend on factors indepen-dent of the soundness of the design of the PPP itself. Forexample, Ismail and Ajija’s survey study (2011) of perceivedcritical success factors (CSFs) for successful PPP projectsin Malaysia reveals that the top five perceived CSFs indescending order appear to be (1) good governance; (2) com-mitment and responsibility of public and private sectors;(3) favorable legal framework; (4) sound economic policy;and (5) available financial market. In the authors’ survey of179 public and private sector respondents, rankings providedby the former were found to differ slightly from the lat-ter, as public sector respondents perceived the top five mostimportant CSFs to be (1) good governance; (2) commitmentand responsibility of public and private sectors; (3) projecttechnical feasibility; (4) transparent procurement process;and (5) favorable legal framework. On the other hand, pri-vate sector respondents perceived the top five most importantCSFs to be (1) good governance; (2) available financial mar-ket; (3) favorable legal framework; (4) commitment andresponsibility of public and private sectors; and (5) soundeconomic policy. The two factors ranked as least important

for PPP success were government involvement by providingguarantee and political support. The authors further elabo-rated on the importance of each factor—namely that goodgovernance is necessary to avoid PPP failure, that com-mitment is essential to ensure that PPP goals are attained,that favorable legal frameworks are needed to prevent cor-ruption, that sound economic policy and a stable economicenvironment will reduce risk and allow private sector part-ners to operate with confidence, and that easy access tofinancial markets—through the availability of flexible andattractive financial instruments such as debt, equity, supplierand purchaser credit, and securities—is important to enableprivate financing of PPP projects. The authors observed thatat the time of the study, no specific legal framework for PPPprojects in Malaysia was in existence. Moreover, the authorswere worried by the fact that respondents ranked “appro-priate risk allocation and risk sharing” as a lower concernfor PPPs. They argued that authorities should emphasize theimportance of risk and reasonable risk-sharing in order tomaximize value-for-money achieved from PPPs.

Sundaram and Chowdhury (2009) caution that PPPs indeveloping countries may not yield anticipated results asgovernments often lack the institutional and human resourcecapacity to handle the complexities of PPPs, especiallywhere financial contracts are concerned. As such, PPPs cansuffer from corruption, cronyism, and monopolies. Transferof risk to private contractors may be partial, and govern-ments may have to step in if something goes wrong. WhilePPP contracts may initially appear to relieve governments ofheavy investment expenditures and seem to improve fiscalbalances, government commitments to pay for future serviceflows and other contingent liabilities pose economic effectsthat are similar to public debt accumulation. Thus PPPs maynot necessarily entail lower capital costs in the long run.

METHODS

A literature review search was conducted to determine thetype, extent, and content of information on health sectorPPPs in Malaysia and on factors leading to success or failurefor these arrangements.

Searches using keywords such as “Malaysia AND healthAND public–private partnerships”, “Malaysia AND healthAND public–private integration”, and “Malaysia ANDhealth AND partnerships” were conducted using onlineinternational databases such as PubMed, Medline, andGlobal Social Policy. Searches were also conducted ononline repositories of major Malaysian universities such asUniversiti Malaya (UM), Universiti Sains Malaysia (USM),Universiti Kebangsaan Malaysia (UKM), Universiti PutraMalaysia (UPM), UTM (Universiti Teknologi Malaysia),and IIUM (International Islamic University Malaysia).

The methodological framework for selection of articleswas that the studies of Malaysian PPPs must contain rigorous

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analysis of institutional strengths or weaknesses, and theymust also discuss factors that affected “success” or “failure”,as opposed to studies that are purely descriptive in nature.Case studies unearthed and selected for inclusion include thefollowing:

privatization of drug procurement,outsourcing of hospital support services,public–private sector dialysis provision,harm reduction programs involving NGOs and private

providers,domestic violence support collaborations between the

MOH, public hospitals, and women’s NGOs,medical tourism, andmedical education.

Although data from MOH annual reports confirm the exis-tence of other initiatives between public and private hospitalsor public and private sector medical personnel, the absenceof independent reports or assessments of outcomes and fac-tors exclude these PPPs from this review. Of further noteis that although some scholars (Sundaram & Chowdhury,2009) view PPPs as separate from privatization, this litera-ture review considers outsourcing of services as a PPP givenits inclusion in the MOH’s definition of “public–privateintegration” initiatives.

PPPs IN HEALTH IN MALAYSIA

From the perspective of the MOH, public–private integrationinitiatives are often meant to fulfill one or more of thesehealth policy objectives: to increase access, promote equity,reduce operational costs, reduce the burden of governmentin service provision, or correct imbalances between publicand private sectors such as in the area of staff and resourceavailability. Our survey of the literature suggests thathealth care PPPs in Malaysia have a mixed track record inachieving these objectives. This literature review focuseson several case studies of health sector PPPs in Malaysia,highlights associated institutional strengths and weaknesses,and identifies factors contributing to the successes or failuresof those PPPs.

Ghani’s discussion (2006) of PPPs in Malaysia includethe engagement of private sector specialist doctors to providesessional services in public sector teaching hospitals, the pur-chase of services from the private sector (i.e., CT scans,radiotherapy, hemodialysis, and PAP smears), and the pri-vatization or contracting-out of hospital services (e.g., linenand laundry and clinical waste disposal), and even training(i.e., private nurses in public training schools).

More recently, the MOH’s Country Health Plan: 10thMalaysia Plan 2011–2015 (2010) lists several exam-ples of public–private integration initiatives: namely, theoutsourcing of medical services to the private sector, the

employment of private specialists on a sessional or hon-orarium basis, the full-paying patient scheme at selectedhospitals which enables MOH specialists to receive referralsfrom private hospitals, and the approval of locum practicefor MOH doctors which enables the latter to legally practicelocum in private clinics.

Nambiar (2009) argues that in the absence of formalinstitutional processes and transparent institutions, privati-zation or contracting-out may not lead to greater economicefficiency. For example, the privatization of health supportservices (pharmaceutical store and services in 1994, hospi-tal support services in 1996, and medical examination offoreign workers in 1997) was fraught with structural defi-ciencies. There were no institutional structures in place priorto privatization, regulatory companies appointed lacked theessential capabilities required, and the appointment of anadvisory company to oversee another company promotedoverlapping roles and unnecessarily raised regulatory costs.Consequently, concessionaires were selected despite lackingindustry experience, maintenance and monitoring of equip-ment was not done according to guidelines, and contractstaffs were not well trained. Nambiar stresses that privatiza-tion without the necessary institutional infrastructure reducespotential gains, hence the importance of proper regulation,evaluation systems, and transparency.

Mustapa, Mustapa, Ismail and Ali’s (2012) study ofincreased operational costs incurred in the process ofoutsourcing hospital support services hints at the possiblefinancial risks associated with PPPs of a similar design.The authors note that despite the proposed benefits ofoutsourcing, the practice runs the risk of incurring addi-tional transaction costs, defined as the “ex ante costs ofdrafting, negotiating, and safeguarding an agreement and,more especially, the ex post costs of maladaption and adjust-ments that arise when contract execution is misaligned asa result of gaps, errors, omissions, and unanticipated dis-turbances; (and) the cost of running a system” (“Overviewof Outsourcing”). In Malaysia, the cost of health care sup-port services increased from £25 million in 1996 to nearly£69 million in 1997. General cost increases were attributedto costs arising from compliance and quality assurancemechanisms, and the preparation and negotiations associ-ated with concession agreements. Moreover, the transfer ofthe workload to private providers resulted in risk-aversebehavior. Private providers also increased contract pricesto cover perceived higher risk. While poor record man-agement makes it impossible to pinpoint outsourcing asthe sole cause of increased operational costs, the authorsnonetheless caution that “managing understanding, efficacyand transparent relationship between the service providerand the host organisation is very crucial . . . (without) atransparent understanding of the management strategies andhaving mutual understanding with vendors, the choice tooutsource might result in bad consequences” (“Overview ofOutsourcing”).

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Similarly, Babar and Izham’s comparison (2009) ofpre-privatization drug prices versus post-privatizationdrug prices suggests that contracting-out practices inPPPs can result in greater inequity and higher consumerburdens if price regulation is lax and monopolies exist.Pre-privatization prices (1994) were compared withpost-privatization prices (1995–1996), which in turnwere compared with those of 1997–2000. Furthermore,1997–2000 prices were compared with those of 2001–2003.The findings were that prices increased by 10.42% in1995–1996, decreased by 3.37% in 1997–2000, andincreased by 64.04% in 2001–2003. Some price increaseswere several hundred-fold compared with the previous year,and did not follow any pricing formula. The authors notethat these price increases pose a hurdle to drug accessibility,and recommend that a medicine pricing policy and rationalpricing structure be instituted to ensure transparent pricing.These studies indicate that strict government monitoring andregulation of PPPs is essential in order to maintain equityand prevent excessive cost increases.

In contrast, the provision of dialysis services in Malaysiahas been hailed as a largely successful PPP. Lim, Goh, Lim,Zaher, and Suleiman’s study (2010) argues that governmentreforms to encourage private providers to provide dialysistreatment (while taking care to subsidize needy patients andensure a level playing field instead of practicing “crony capi-talism”) has resulted in greatly expanded and fairly equitableaccess to dialysis services. Between 1990 and 2005, dialysistreatment rates in Malaysia increased more than eightfold,reaching a level comparable to rates in developed countries.This transformation was brought about largely through theMalaysian government’s large-scale purchase of dialysis ser-vices from the highly competitive private sector. In 1999, theMOH allocated additional funds to develop more public dial-ysis facilities and provided matching capital grants to NGOs.Alongside reimbursements and subsidies for private sectordialysis treatments instituted by government-run bodies (i.e.,the Social Security Organization, Islamic Baitumal socialwelfare organizations, and the Public Services Department),the MOH also began subsidizing dialysis at private facili-ties for eligible patients in 2001. The current governmentpolicy is that all qualified providers may offer their ser-vices to patients eligible for public financial assistance, andthat the government will reimburse providers for each treat-ment episode. Eligible patients are generally free to choosetheir providers, who have to compete for business. The gov-ernment also permitted private-sector employees to trainat public institutions to become nephrologists and dialysisnurses, and lifted restrictions to allow other practitioners—such as general physicians and nurse aides—to performsome duties and thus help to meet the demand for dialy-sis workers. Reasonable regulations and low-entry barriershave also helped to make the Malaysian dialysis marketone of the most competitive markets in the world. Private

dialysis provision has expanded rapidly, and the cost of pri-vate hemodialysis treatment (adjusted for inflation) has inturn decreased by 45% from 1990 to 2005. Thus, the authorsargue that the large-scale public financing of private dialysisalongside the provision of physical and human resources torapidly expand a competitive market and increase efficiency(without reducing quality or equity) should provide a modelfor further health care partnerships.

Another successful area in PPPs in Malaysia lies inthe area of promotion of medical tourism (Chee, 2010).While the studies identified were mainly comparative stud-ies between Malaysia and other Southeast Asian countries(Chee, 2010; Pocock & Phua 2011), there were salientpoints to take note of with respect to the actions of theMalaysian state. Chee contends that Malaysia was amongstthe first Asian countries to promote international medi-cal travel as a way to earn foreign exchange. As opposedto some of the European welfare states, developing Asiancountries had few reservations about getting onto the med-ical tourism bandwagon. The 1997 Asian financial crisisdiverted many Malaysian health care consumers from pri-vate facilities to public facilities, with the latter witnessingan 18% increase in patients (Wong, 2008). Currency depre-ciation also resulted in price increases of between 20%and 120% for imported pharmaceuticals and medical sup-plies (Rabobank International Asia Pacific, 1999). Privatehospitals experienced 4–9% deterioration in their operatingmargins (Rabobank International Asia Pacific, 1999). Privatehospitals responded by promoting their facilities and servicesabroad, and the government stepped in to assist by setting upthe National Committee for the Promotion of Medical andHealth Tourism (MNCPHT) (MOH, 2002).

This current successor to the MNCPHT is the MalaysiaHealthcare Travel Council. There is also the Health TourismSection under the Corporate and Health Industry Division ofthe MOH (MOH, 2005). The number of foreign patients hasincreased almost tenfold; from 39,114 in 1998 to 374,063 in2008, even if these figures include foreigners who are res-idents of Malaysia and foreign visitors who needed med-ical care while in the country (Chee, 2010). However,the Malaysian medical tourist industry is largely regional,with 76.8% of medical tourists coming from Indonesiaduring 2006–2008, and smaller proportions coming fromJapan (3.4%), Europe (2.7%), and India (1.8%) (MalaysianTourism Promotion Board, 2006, 2007, 2008). Revenue frommedical tourism is of great significance to certain privatehospitals in Malaysia; for example, about 20% of the patientsin the Pantai hospitals chain are foreign (Nomura AsiaHealthcare Research Team, 2009).

The Malaysian state also carries out other efforts todevelop and support the medical tourist industry. Regulationsrelated to the advertising of medical services were relaxed.A national accreditation system, based on collaborationbetween the MOH and the Malaysian Society for Quality

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in Health (MSQH), was set up as a cheaper alternative tothe more expensive Joint Commission International (JCI)accreditation scheme. Tax incentives were also given to pri-vate hospitals, allowing them to claim double deduction forexpenses incurred on overseas promotion of their services.Revenues from foreign patients were also exempted fromcorporate tax. The Malaysian government also organizesand conducts medical tourism road shows and marketingpromotions.

Proponents of medical tourism argue that it earns for-eign exchange, contributes to the economy, and helps lessdeveloped countries escape from dependency on extractiveindustries. On the other hand, critics have voiced their con-cerns over the effect of medical tourism on the rest of thenational health care system and the allocation of health-related human resources. Chee argues that the problem ofoutflow of public sector medical expertise to the private sec-tor has been exacerbated by medical tourism. Many of thesearguments are echoed by Pocock and Phua (2011), who alsocontend that because trade and tourism are international inscope while health care coverage is a national matter, thechances of policy incoherence are high. There needs to beconvergence of the goals of the health, trade, and tourismministries.

The rising demand for medical personnel has also ledto the growth of public–private cooperation in the settingup of private medical schools and training of medical stu-dents in Malaysia. Some medical schools are government-initiated partnerships with reputable overseas universities(e.g., Malaysia’s Perdana University and its graduate medi-cal program established in partnership with Johns HopkinsUniversity). Some overseas universities have also beeninvited to set up campuses and medical schools in Malaysia(e.g., Australia’s Monash University and its medical schoolat its campus in Malaysia). Medical students in private med-ical schools can include those sponsored by governmentagencies. Government hospitals are often used as teach-ing hospitals by private medical schools under agreementswith the MOH. An example would be Seremban Hospital,which serves as the teaching hospital of the private sec-tor International Medical University (IMU). The lecturersof IMU are expected to contribute some of their time toSeremban Hospital patient services while MOH specialistdoctors are also expected to assist in the teaching of IMUmedical students.

The WHO’s 2011 report has recognized the success ofPPP harm reduction efforts in Malaysia. The report deemsstrong government leadership and sustained partnershipsamong government agencies and NGOs as a key elementof Malaysia’s success in having integrated harm reductioninto the national strategic plan on drugs and HIV/AIDS.Two core programs—the methadone maintenance therapy(MMT) project and the needle and syringe program (NSP)—were launched in 2005 and 2006, respectively, and expanded

dramatically over 5 years. The WHO (2011) notes thatelements of good practice in the expansion include:

the rapid scale-up of a comprehensive range of harm reduc-tion services made available through a variety of outlets andsettings; deployment of effective policies and procedures toguide implementation and monitoring and evaluation (M&E)of programmes; accreditation and registration of serviceproviders as well as parallel training and capacity build-ing; allocation of significant proportions of the nationalbudget to support implementation; excellent collaboration,communication and partnerships between the stakeholdersinvolved in the national response to drugs and HIV/AIDS;high-level commitment and support from key agencies fromvarious sectors; and integration of harm reduction servicesinto existing health systems. (n.p.)

The WHO also notes that the best practices of NSPs lie in:

. . . the existence of high-level commitment and dedicatedstaff on the frontlines . . . (exemplified by) the rapid scale-up of services and expansion of coverage to meet nationaltargets, along with significant financial investments by thegovernment in the national programme . . . (in) addition,the diversity of NSP access points as well as their growingintegration with other health and social care services demon-strates that a sophisticated health systems approach was putin place to scale up NSPs, in parallel with MMT services,primary health care, health education and referral networks.. . . PWUD (persons who use drugs) have been empoweredto take an active role in the delivery of essential services andhave been provided official licence by the authorities. (n.p.)

The success of both programs is evident in increased accessand client response to treatment services. While the first pilotMMT project began in 17 centers in 9 states, as of June2010, 211 MMT access points including 21 registered pri-vate clinics and 200 general practitioners (GPs) dispensedmethadone and other substitution drugs. As of June 2010, anestimated 20,000 individuals were accessing fee-based sub-stitution therapy through private practitioners, exclusive ofanother 13,471 individuals registered at the 211 free MMTservice outlets. As for NSPs, three pilots were implementedin 2006 through local NGOs; by 2010 more than 20 NGO-based NSP sites were in operation and complemented byNSPs at health clinics, with an overall total of 24,999 clientsserved. However, while the WHO praises the high degreeof cooperation and collaboration, consistent support, andtransparency levels between government and civil societygroups, it also argues that certain components require furtherattention. These include

human resource capacity across all interventions, revision,and development of standard operating procedures (SOPs)for each intervention in the comprehensive harm reduction

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PUBLIC–PRIVATE PARTNERSHIPS IN HEALTH IN MALAYSIA 511

package, the need for rapid scale-up of coverage of key inter-ventions, especially counselling, and condom distribution,harmonisation of laws with existing practices and decisionsin the country, as well as the development of a nationalcommunication strategy. (n.p.)

It should be noted that private sector GPs generally pre-scribe suboxone instead of methadone to their patients. Theformer is more expensive and results in increased costs forthe patient. GPs have also expressed concern over the timeneeded for follow-up and counseling of Persons Who UseDrugs (PWUDs) and worry about financial constraints ofgovernment fee reimbursement levels being set too low tocover operational costs.

Other studies of harm reduction PPPs in Malaysia notestrengths and weaknesses of past and present practiceswhich are worthy of attention. Narayanan, Vicknasingam,and Robson (2011) observe that apart from being front-line players in program implementation, NGOs have servedas a crucial bridge between state, civil society, and otherstakeholders. NGOs were well positioned to convince inject-ing drug users to opt for medical treatment, educate theirpartners, draw academics and medical practitioners intoadvocacy efforts, and engage the religious lobby of Malaysiawhile deflecting criticisms from unconvinced Islamic groupsaway from the state (albeit with varying degrees of suc-cess). On the subject of compliance issues, Vicknasingamand Mazlan (2008) note that prior to the MMT program,the government implemented an agonist maintenance treat-ment program using buprenophrine mono-tablets in 2001.From 2001 to 2005, more than 500 medical practitionerstreated about 30,000 dependent individuals; however, thepractice was marred by occasions of buprenophrine mis-use. Physicians were found prescribing large quantities ofbuprenophrine for unsupervised use and patients were notprovided drug counseling and other psychosocial services.As a result, the government limited the use of buprenophrineat the end of 2006. In a more recent 2010 study of MMTpractices at a NGO-run center and private clinic, Mohamad,Bakar, Musa, Talib, and Ismail discovered that lower dosagesof MMT were routinely prescribed despite clear guidelineson MMT dosages, resulting in lower retention rates. Theauthors concluded that “ophophobia” among doctors—asindicated by the hesitation of doctors to prescribe opiates outof fear of promoting addiction—results in inadequate dosesand premature termination of MMT. The authors concludethat this problem must be remedied through further edu-cation of health professionals and extensive monitoring toensure that guidelines are adhered to.

Lastly, Colombini, Ali, Watts, and Mayhew’s study(2011) of One-Stop Crisis Centres (OSCC) suggests possiblereasons which contribute to the failure of PPP arrangements,and reveals examples of institutional and structural difficul-ties that PPPs may face at the ground level, in particular

where NGO involvement is concerned. The 1996 OSCCpolicy aimed to link clinical services and NGO support(i.e., legal aid, counseling, and religious support) for abusedwomen who show up at hospitals. Although the policy wastop-down and formulated by the MOH, the policy documentof 1996 had no clear objectives, no proper guidance for repli-cation, no allocated funds, and no monitoring system. Theroles of NGOs were not clearly defined and this resultedin hospitals expecting NGOs to take on more than they areable to do without state financial support. The debate overwho should be responsible for delivering and funding theOSCCs’ nonclinical services led to rifts between NGO andhospital staff. Furthermore, the MOH’s lack of prioritizationof OSCCs and general loss of political support for domes-tic violence concerns led to the decline of OSCC services.A follow-up study by Colombini, Mayhew, Ali, Shuib, andWatts (2012) focusing on the implementation of OSCCs atdifferent hospitals reveals that practices at individual hos-pitals were influenced by organizational constraints such asa lack of clarity in standard operational procedures (SOPs),lack of training on domestic violence, a scarcity of on-sitespecialized staff, time constraints, limited allocated budgets,and limited referral options for abused women. Although theOSCC policy was nationally implemented, the model wasconstrained by local resources and marked by fragmentationat the local hospital level, suggesting that a single integratedmodel is not possible for all levels of hospital care across allregions. Both studies imply that in order to create successfuland sustainable PPPs—especially when NGOs are involvedand staff and resource limitations are a concern—it is impor-tant to have institutional support in the form of clear policyguidance over roles, responsibilities, and operational details,as well as sustained financial support for the expansion ofprograms and services.

DISCUSSION

The government of Malaysia embarked on the path of pri-vatization as early as 1983 under the premiership of Dr.Mahathir Mohamed. This policy was continued under subse-quent Prime Ministers. More recently, the strategy of “PPPs”was adopted and a UKAS was actually established in theinfluential Prime Minister’s Department in 2011. Malaysia’sexperience with privatization and PPPs may hold usefullessons for other nations. The record is mixed, with successesand failures. This review was carried out to identify rigor-ous (i.e., going beyond mere description) studies of healthcare PPPs in Malaysia and to identify factors that made thesePPPs “successes” or “failures”.

Some “successful” PPPs we identified include the provi-sion of dialysis services, harm reduction programs (MMTand the NSP), the promotion of medical tourism, and theproduction of more health care personnel through private

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medical education. With respect to the provision of dialysisservices, this was a “success” because access was greatlyimproved without incurring high costs for the governmentand without endangering patients through low quality care.The MMT and NSP programs can also be considered “suc-cesses” for similar reasons.

In the case of medical tourism, although clients are mostlyfrom neighboring countries such as Indonesia, the participa-tion of public bodies such as the Malaysia Healthcare TravelCouncil has helped to boost the number of arrivals and rev-enues generated. However, critics have pointed out that thegrowth of medical tourism may accelerate the outflow ofexperienced health personnel from the public sector to theprivate sector.

In the case of private medical education, the help given bythe government (such as allowing public hospitals to be usedas teaching hospitals by the private sector) has led to signif-icant growth in this area. This “success” has led to worriesabout overproduction of doctors, nurses, and pharmacists inthe near future.

The (arguable) “failures” include drug procurement viaprivatized agencies, the contracting out of hospital supportservices, and the program to deal with domestic violence viaOSCCs. These can be considered “failures” mainly becauseof the financial dimension; that is, costs of drug procure-ment and hospital support services increased significantlyafter privatization and contracting out. The domestic vio-lence program failed partly because of lack of resources butalso because of policy and organizational confusion.

CONCLUSION

Despite the limited number of PPPs surveyed above, gen-eral conclusions can be drawn on the factors influencingfailures or successes of health PPPs in Malaysia. Critical fac-tors for success include regulation, transparency, clear policyguidance and clarity on operational procedures and respon-sibilities, proper evaluation mechanisms, sustained financialsupport (especially for NGO partners), and unwavering com-mitment from policy-makers to see the partnerships through.Care must be taken to ensure that the potential costs ofPPPs—such as increased public financial commitments asa result of contracts and subsidies that go awry, time andresources spent on regulation and monitoring of performanceby private sector for-profit and NGO partners, and poten-tial misuse and abuse as a result of noncompliance—do notoutweigh or overshadow the anticipated benefits of thesepartnerships.

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