HEALTHCARE SYSTEM IN MALAYSIA Malaysia has enjoyed stable economic and political growth over the past 50 years

after gaining its independence. Being a dynamic and prosperous country, Malaysians tends to be healthier and have a longer life expectancy. This can be shown by the level of overall health achieved which is also a good indication of a successful country. Good health is very important as it is the essence of a long, fulfilling, productive and meaningful life. It also contributes to the prosperity and overall social stability and satisfaction towards the countrys management. In Malaysia, the health care services are provided by various health care providers, mainly divided into three main groups, the private, the public and the Non-Governmental Organizations (NGOs). The main policy-maker and regulator bodies are still in the hands of the Government, under Ministry of Health (MOH). Under this Ministry of Health, Malaysian have no doubt enjoyed a comprehensive range of health services as the Governments are very committed in achieving its main principle of universal access to high-quality healthcare to the people through all means including conventional means, the allopathic and Traditional and Complementary Medicine (TCM) practices in all levels of care, be it primary, secondary or its tertiary health care facilities. This commitment is ensured not only through the Ministry of Health but also by the dominance of public health services, which ranges from doing health promotions, illness preventions, curative and rehabilitative cares. The public and private sector healthcare providers play the most important role in the provision of healthcare services in Malaysia. The public sector however is still more dominant. In the public sector, under the Ministry of Health is the main government agency responsible for providing the healthcare services in the country. Other ministries do provide healthcare services include the Ministry of Higher Education, Ministry of Defense, Ministry of Internal Affairs and Ministry of Women, Family and Community Development. The health system is highly centralized with most planning and organization of health services being carried out centrally. There are four types of hospitals in the public sector under the Ministry of Health. They are:1. 2. 3. 4. district hospitals, state general hospitals, national referral center and the special institutions non-MOH hospitals.

The district hospitals typically have between 100 and 200 beds and are more normally run by 6 to 10 medical officers. State general hospitals have 500 to 1500 beds. Each state has one state general hospital except for the state of Sabah which has two. These hospitals provide outpatient and inpatient care in general surgery, pediatrics, medicine, obstetrics, gynecology and psychiatry. The healthcare services are provided by both the specialist and non-specialist medical officers. The national referral centre is the highest level of hospital in the hierarchy. This hospital has 2800 beds and is located in Kuala Lumpur. It is the most equipped hospitals and provides some services that other hospitals are lacking such as neurosurgery and radiotherapy. Although it

is the main centre for referrals especially for cases which needs specialized cared not available in other state hospitals, it still provides its own outpatient care for the surrounding populations. There are seven special medical institutions that provide inpatient services for specific diseases in the country. They are:1. One National Tuberculosis Centre, 2. One hospital catering for leprosy 3. Five mental hospitals

Private health providers in Malaysia can be divided into four main groups, which are the private practitioners, private hospitals, private non-governmental organizations and practitioners of traditional medicine. Private practitioners are registered doctors who provide services through private clinics. Currently, there are 5642 private general practitioners clinics and 535 private specialist clinics in Malaysia. Private hospitals are licensed under the Private Hospital Act 1971 and are defined as any private facility with more than one bed. Therefore, they were great variations in the size of the hospitals, ranging from 2 to 406 beds. As mentioned earlier, the majority of the healthcares services are carried out through the Public sector, with which the cost are heavily subsidized by the Government by means of Government Hospitals, Poli-Clinics and the Mother and Child Health Clinics. They are financed mainly from taxes on earned income provided from the central government. Other sources of financing for health services are private voluntary insurance, social security, and user fees. Private voluntary insurance is gaining popularity now because there is no compulsory insurance or National Health Insurance in Malaysia yet at the moment. It is estimated at least one-quarter of the population is covered by some form of voluntary health insurance in Malaysia. The newly emergence of Klinik 1 Malaysia is also an improved effort to cater for the more remote areas. The healthcares are provided at a very low cost and the system is deemed very fair in the sense that it is for all without prejudice and nobody is excluded from receiving care on the basis of ability to pay. Highly subsidized user fees are charged for inpatient and outpatient services in all public hospitals. Under the Ministry Of Health fee schedule, patients are charged RM1.00 for treatment in general outpatient clinic and RM5.00 for specialist care in public hospitals. Services in the health centre of rural health units are free of charge. Charges for inpatient care are capped at the maximum of RM500 per admission in the third class wards of the public hospitals. However, with the emergence of Private Health care, the quality, convenience and efficiency of these Government premise were being brought into questions. On the other hand, the private sectors of the healthcares were provided through the means of private hospitals, private clinics and community pharmacies at a cost. These services are nonsubsidized and require full payment by the patients. However, the patients can usually claim/reimburse part of the treatment costs, usually through Personal Health Insurance, Pertubuhan Keselamatan Sosial (PERKESO) if they were working in the private sector or through the government if they are civil servants. Since the private sectors normally charges for their services, they are usually of higher quality care and more convenience. This leads to a large number of people paying for their services that they could otherwise get for free or at a highly subsidized rate.

Since gaining independence, in order to develop the nation, the government had developed a 5-year plan. Originally, it is known as the Malaya Plan which first started in 1956. With the inclusion of Sabah and Sarawak in 1963 to form Malaysia, the plan was renamed to 1st Malaysia Plan (1MP) which was then formulated and subsequently implemented in 1966. The Malaysias health planning process has since evolved from purely a top-down pragmatic approach into a mixed top-down, bottom-up process that is rational and evidence based. However, by the end of the 7th Malaysia Plan (7MP), this was again evolved into a more systematic approach or plans. By the 8th Malaysia Plan (8MP), the policy-to-practice approached was adopted with the introduction to a systematic monitoring and evaluation process. The objectives and strategies are measured to create more opportunities for better and greater integration of various health and health related agencies which then further enhanced and improved by the 9th Malaysia Plan (9MP). In 9MP, a strategic planning approach was introduced in the Mid Term Review (MTR) of the 9MP and the outcome-based evaluation was started. This then leads to the 10th Malaysian Plan (2010-2015) with the theme 1Care for 1Malaysia. In order to achieve the Vision 2020 dreams of becoming a Developed Nation and High Income Nation status, in line with the 5 National Mission Thrusts (2006-2020), 6 National Strategic Directions have been identified to support these thrusts. These are: 1. Competitive Private Sector as Engine of Growth, 2. Productivity & Innovation through K-economy, 3. Creative & Innovative Human Capital with 21st Century Skills, 4. Inclusiveness in Bridging Development Gap, 5. Quality of Life of an Advanced Nation and 6. Government as an Effective Facilitator In the previous Malaysian Plan, the 9th Malaysian Plan (9MP) with the theme towards achieving better health through consolidation of health services, this is seen as being consistent with the 5th National Mission Thrust (Quality of Life of an Advanced Nation) which is to improve the standard and sustainability of quality of life. In order to monitor the progress, the 9MP were divided into two primary goals and four supporting goals. The primary goals are: Prevent and Reduce Disease Burden Enhance Healthcare Delivery System The supporting goals are: Optimize Resources (including health human resource) Enhance Research and Development Manage Crisis and Disasters Effectively Strengthen Health Information Management System During the Mid-Term Review (MTR), using The Outcome Based Assessment Approach as was introduced, all government agencies and Ministries were required to ensure that the

projects and program conducted during the 9MP were in line with the 5 National Missions Thrusts as listed below: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 The 4th National Mission Thrust then became the basis of all health sector activities and programs planned during the 9MP. It was then further suggested during the Midterm Review that healthcare services need to be further emphases to reducing the gaps in changing disease patterns, between rural and the urban services as well as meeting increasing demands of the population. A lot of recommendations were included to increase the support for health promotion, health education and healthy lifestyle practices. This indirectly leads to the idea that the delivery of healthcare services should be affordable and easily accessible at all levels of care via the collaboration among the public and private sector and providing disease-oriented services. The Primary and secondary care should focus on healing and recovery and there must be an assurance that there are enough public sector health personnel and options should be given to manage the increasing cost of healthcare. However, there were inadequate efforts towards consolidation of health services although it was the main thrust of the 9MP. It was then noted that due to lack of organized and appropriate data, there was a need for active sector stewardship to assist in developing more appropriate end types of indicators that would be more useful for policy/health planning and decision-making. It is noted that human resource factor was given as the reasons for most non-performance during the 9MP. In the 10th Malaysia Plan (10MP), the issues and challenges faced will be similar to those in the 9MP. Issues on globalization and the increasing trend of private health care spending pose a great challenge and concern on maintaining the strength of the current healthcare system. As can be seen in the National Strategic Directions, The Economic Planning Unit (EPU) has entrusted Ministry of Health to look into the 5th National Strategic Directions. To achieve this, the health sector would have to play the role in other strategic directions, namely the Quality Healthcare and Active Healthy Lifestyle, which were then set as the main Key Result Area (KRA) for the health sector. The final outcome of this KRA is to make sure that there are easy accessibility to quality health care and public recreational and sports facilities to encourage and support the active healthy lifestyle. Therefore, four strategies to be implemented are:Strategy 1 : Establish a comprehensive healthcare system & recreational infrastructure Strategy 2 : Encourage health awareness & healthy lifestyle activities Strategy 3 : Empower the community to plan or implement individual wellness program (responsible for own health) Strategy 4 : Transform the health sector to increase the efficiency and effectiveness of the delivery system to ensure universal access

Based on these four strategies, three KRAs for the health sector have been identified, consisting of:1. Health Sector Transformation Towards A More Efficient & Effective Health System in Ensuring Universal Access to Healthcare 2. Health Awareness & Healthy Lifestyle 3. Empowerment of Individual and Community to be responsible for their health The Ministry of Health (MOH) has been entrusted by the Economic Planning Unit (EPU) to identify Technical Working Groups (TWGs) under the Thrust 4 Mission Cluster Group (MCG) - Quality Healthcare & Active Healthy Lifestyle - involving inter-agencies and multisectoral membership. The Ministry has identified five TWGs as:1. Health Sector Transformation (Service Delivery) 2. Health Sector Transformation (Finance & Governance) 3. Health Sector Transformation (K-economy Human capital, Information Technology, Research & Development / Innovation) 4. Health Awareness & Healthy Lifestyle 5. Empowerment of individuals and community to be responsible for their own health The outcomes, strategies and KPIs identified by the TWGs will then be used to prioritize programs, projects or activities which are in line with the National Program finalized earlier by Ministry of Health and Economic Planning Unit. 5 National Health Sector Development Program that the MOH has identified were:1. Population Health Program 2. Personal Health Program 3. Research & Innovation 4. Human Capital Development Program 5. Technical and Other Support Program These five programs served as the mode to allocate funding for the 10MP. The Malaysian Health System is no doubt of high and equitable health status and at the same time, at relatively low cost. However, due to the increasing and active participation in the private sector over the years, the dissatisfaction towards the Government sectors has risen gradually. There were doubts and questions regarding the public health services responsiveness and their quality of care leading to doubts and mistrust by the community at large. However, Malaysia is still trying to recover from the current economic crisis, trapped in the middle income country for over a long period of time. In order for the 10MP to be successful, the government of Malaysia has set the target of achieving a high income nation by the year 2020. In order to achieve this target, Malaysia would have to make at least make a yearly 5.5 % growth rate in its economy. The government has allocated a total of RM180 billion ceiling as development expenditure for all sectors where RM 15 billion is for the Private Funding Initiative

Facilitation Fund and another RM50 billion (minimum) is predicted to be contributed by private investments under the Private Funding Initiative. World Health Organizations data shows that the overall performance of the Malaysian health care system is remarkably good. One of the indicators, the Health Adjusted Life Expectancy (HALE) at birth, is comparable to that of industrialized countries which stands at about 63 years. This accomplishment is remarkable since Malaysia devotes only 3 percent of its GDP to health as compared to about 6 percent for most industrialized countries. United States devotes 14 percent of its GDP to health. Other indicator such as maternal mortality rates in Malaysia also shows a great reduction of ten folds over the last 3 decades. Malaysia shows good rating on the distribution of health characteristics among segments of the society. This is shown by the difference between male and female life expectancy. When both genders are given equal access to preventive and curative health services, women tend to do better. This pattern is found in Malaysia, where women live from 2.7 to 3.7 years longer than men. Malaysia falls in the same category as countries that have 5 times higher incomes, such as Canada and the United States. Survey data also show that overall utilization rates of ambulatory health services vary little by income group. However, there still a lot of issues regarding the healthcare systems. The main problem faced by Malaysian is related to the healthcare delivery system. Since the government has focused in building a first class referral hospital, they have taken steps to make sure that there is equity in access and provide a comprehensive range of affordable and quality care. This, combined with a good referral system in place, ensures that the majority of their populations can gain access to the appropriate level of care. Unfortunately, even with the private sectors blooming, the public sector still caters with a great majority of the cases, leading to the imbalance in the distribution of resources and workload as public sector shouldering most of the workload in terms of both the complexity and number of patients. The Standard of care is also biased and a large variation in practice occurs in the private sector. Even though, the MOH is guided by a transparent quality assurance programs, the inequity still exist as due to the distribution of facilities. Other governmental agencies such as the Universities, Ministry of Social Welfare and the Local Governments can only provide selected healthcare services. The issue then arises in with questions of how to integrate all these healthcare services with the MOH so that they do not duplicate but complement each other. The public and the private sectors dichotomy systems where they are independent of each other also created another problem, namely the shortage of expertise in the public sector. Even though great efforts have been put in to make sure majority of the doctors are within the public system, doctors, in particular the more experienced specialist, opting for the more lucrative private sector resulting in shortages of experts in the public sector. Since the private sectors receives high fee payments for their healthcare services, the quality of care and service standards in private health sector have been drawing the attention of the society. As the public sectors rely heavily on the budgets given by the government in maintaining its daily operations they are unable to give such care and service standards. Due to the high fees, most people tends to crowd to the public sector as well, therefore reinforces and making the imbalance in the distribution of resources and workload worse. This also drains a lot of the budgets of the

government as the healthcare services which were subsidized heavily relies again purely on taxes and budgets by the government. Even though a good referral system is in place which makes sure the majority of the population is being cared for, the more rural area such as Sabah and Sarawak is still left out as compared to those in the urban areas. The distance, availability of facilities locally and the cost is the major issues in the more rural area. Since the private healthcare sector charges high fees, most of the population tends to overcrowd the public sector, this increases the financial burden, coupled by lack of expertise and under-facilities, the cost-effectiveness of treatment is usually in doubt. This also creates doubt in sustainability of this system. The overcrowding of patients also reduces the quality of care is greatly. This further is worsen by the wastage especially in the management department which often been seen as non-efficiently. The conspicuous absence of a way to allocate health resources equitably, effectively and efficiently makes it harder and harder for many marginalized patients to get services they need. The inpatient care, choice of care provider, prompt attention (waiting time and travel time), space of basic amenities, social support and autonomy (treatment information and involvement in decision making) were domains where our healthcare systems suffers the most. This is mainly due to the fact that the government lacks system where incentives were given to improve the quality of care and productivity. Further, unlike in the public sector, the private sector does not have a systematic collection of treatment or outcome data, like the National Indicator Approach in the Quality Assurance Program in Ministry of Health (MOH) hospitals and therefore has no means of implementing mechanisms promoting best-practice care, such as pay-for-performance programs. The lack of communication, information and advice makes it hard for patients, hospitals or physicians to compare outcomes or for patients to compare providers when deciding where to seek treatment. As the population expands, the increase in the number of admissions and number of outpatient visits will also increase, creating even more demand for services, therefore increasing the cost of healthcare even further. It is estimated that there will be a 3% increase in admissions to MOH hospitals annually. With advancement in medical equipments, technologies and medical updates, improved delivery of care can be seen. However, these come with a cost which includes user training, maintenance, infrastructure redesign and renovation. New and more advanced drugs are also more costly and as the demands for these drugs will also increase especially in the more well-informed patients. Migrant workers also add costs to healthcare as they bring to this country various re-emerging infectious diseases that require proper control and treatment. Commercialization of healthcare as marketed by many private laboratories also increases inappropriate diagnostic investigations. All these will increase cost of treatment and further increase the cost of living which greatly plagues the nation. The Malaysian healthcare system also lacks the ability to spark public health awareness. Due to the wide gap between communitys knowledge and their behavior, public health is suffering greatly. The environment, such as the lack of legislative, its enforcements and lacking skilled personal nor its human resources, public awareness and health knowledge remains low. With the increase in technology, more information is readily available. However, due to the lack of resources and legislative, misleading or contradicting information may spread widely without proper control and filtering. This poses great risk especially on the community with poorer level of education.

In order to progress, Malaysia must find ways to increase its financing system. This can be done in a lot of ways such as increasing its cost efficiency, reducing wastage and eliminating liabilities. Up to today, the country has relied heavily on government subsidies, out of pocket payments, employer payments and insurance premiums to finance health care. At some point, sooner or later, the increasing burden of these financing mechanisms will place too much stress on the nations economy and drag them down. The healthcare system needs to find a way to selfsustain its own needs and at the same time rely less on the government budget allocation. This can be done first by having a proper financing and provider payment system. The current heavily subsidized fee must be revised and portray the financial ability of the patient. In a way, some people might claim it is unfair. However, those who actually earn a lot should help and subsidize those who are less fortunate and more deserving. Due to the current unbiased stand of the current payment system, a lot of wastage was seen as the rich hogs the public sector, demanding and requesting new, unnecessary medications and depriving the needy and people who actually need help from getting proper healthcare. Some of these more fortunate people were seen either wasting the medication and some were even seen selling the expensive medication for profits. Therefore, by implementing a system that reflects the financial ability of the patient, indirectly the rich will help subsidized the poor and wastage of medication will greatly reduce, therefore reduce the burden of rising cost of health care. Most of the developed country has some sort of National Health Insurance where a small portion of incomes were used to pay the Health Insurance. As long as the amount is acceptable, this move actually helps the people themselves. By having a National Health Insurance, everybody is covered under some sort of insurance and when one was faced with a situation where he or she can no longer affords the medical bill due to sudden illness or death, these insurance will come in handy, easing the burden of the patients and their families. As the payees are from the working class, they should be able to put aside a tiny portion of their income for a more protected future. This, of course needs some in-depth discussion and agreement with the general population as it affects individual earnings. To increase its effectiveness, the Malaysian Ministry of Health (MOH) might consider corporatizing the following: Corporatize integrated regionalized health services (non-profit, government-owned) Corporatize specialized medical institutions (e.g. national referral hospitals) Selective technical functions (e.g. Food Quality Control and Drug Quality Control). By corporatization some of its current services with monitoring and incentives, it can overcome a few major problems which existed in the current MOH structure. First, shortage of resources, which is explains why Malaysia devotes only a small share of both its government budget and its GDP to health (3%). As Government tries to rebuild the countrys economic growth, it is reluctant to devote substantial additional public resources to health. The corporation of the health structure will allow them to shift, particularly for curative medical care and some regulatory functions, to non-budgetary sources. However, even though some of its services were corporatized, care must be taken to protect the interest of the public. The government will need to instill some sense of public mission among the staff. To maintain this sense of "public mission" among staff, the top

management should be chosen who share this vision, and the by-laws and procedures should be made to reinforce the goal that the purpose of the corporatized units is still to attend to the population and improve health status as shown by the kinds of performance targets. These corporatized services should be closely monitored. This will encourage the involvement of the private sector and any other Ministry to work hand in hand with the Ministry of Health and therefore creates a bond for the future path where more partnership between the private sector and public sector can be seen. By having corporatization of some of its services, it will allow some flexibility, such as types of personnel for which government salaries are far away from market conditions to have a more realistic salary scale. Based on amounts of unfilled posts, this discrepancy seems to apply most at the bottom and top of the position of the hierarchy. The MOH can also regionalized or adopt a zoning method. Instead of having each state to monitor their own activities, they could create 3 to 6 zones where monitoring over their activities such as personnel structures, recruitment of outstanding management personnel, monitoring and auditing could be easily done over 3 to 6 zones rather than over 14 states. This will greatly reduce wastage of time, effort, redundancy and repetitive works, thus making it more efficient governance. This entails independent boards of directors with representatives appointed by different Ministries, local government, professional associations, independent experts, and community and consumer representatives responsible for appointing CEO, and open sessions and reporting requirements. Another where a lot of wastage can be greatly reduced is having the right person doing the right work. At the moment, the amount of ratio of civil servant to population is one of the highest in the world. This will create imbalance and further makes budgeting worse as subsidized burden goes up while the resources to help the budget goes down. The government should review its civil workforce and reduce unnecessary personal. If we look at the current civil workforce and comparing to the work done, it shows a very disappointing inefficiency. The current civil workforce are not motivated, appears lazy and underperforming their duties. The government should focus in increasing motivation and performance rather than increase the volume of civil servant to tackle issues related to inefficiency of public services as this will further creates more inefficiency and therefore leads to more wastage. The root cause of this inefficiency is due to lack of punishment for under-performing staffs. The current workforce has the mentality that is once I am in the civil service, I will get paid regardless of the work I do and there is nothing anybody can do about it as long as I do not break any law. This is a very serious problem as they see themselves as immune to being sacked, which leads to working with minimal effort to pass time and let others do their work for them. This will then leads others to follow as they feel it is unfair for them to do more work but get paid the same amount. Therefore, inefficiency rises rapidly and inability to cope with workload to meet demand and the government solution to this is therefore hire more unnecessary civil servants to cater the demand and then the whole cycle repeats. To break this cycle, we first must implement a system for rewards and punishments. If the personal is unable to perform, it should not be absorbed into the civil service in the first place. If a personal performs better, we should reward such efforts. This will not dramatically increased efficiency and quality of work, it will reduce the amount of wastage due to having unnecessary personal. Standards or judging methods should be set up to make sure the minimum efficiency is met while good performers are

rewarded. This can also be used on other operational activities like encouraging and eliminating tender or contracts given to the private sector. Last but not least, the current system does not identify the need or over supply for certain areas. A lot of unnecessary skills/professions that has already oversaturated in the market are still being churned out in bulk yearly, leading to high unemployment rates among certain skills or professions. If the government absorbs all these extras, and paying them high salary due to them being a skilled worker which is what the government especially MOH is seen doing, this increases financial burden and at the same time reduces the moral and motivation to these young achievers. This is not only seen as backlash on the government system, it also waste the time and efforts of our younger generation future as they are stuck in a profession that is not appreciated. These bright teenagers could have went into another field where they could actually help the country to progress and solve the problems where certain skills in the country is lacking and at the same time, they can be more appreciated and encouraged to achieve higher ambitions that could propel our country into a brighter, more competitive and high achiever country. The same could be said with skill or professions that are highly needed. If the government could identify and prepare our future generations with such information, we could easily overcome our shortage in the said area and no longer rely on the use of foreign specialist which in terms not only reduces outflow of medical expenses but can also help in increasing the influx of medical income from other countries. The final area that we badly need is a regulation and increase public awareness. Our country has been using the same law since the formation of Malaysia. Some of the laws are very outdated and certain things need to be reorganized to allow smooth flow into the futuristic and more efficient healthcare services. These laws should not burden the society nor the healthcare providers in giving their best and at the same time controlled heavily under the watchful eyes of the regulators. Health, as many organizations such as World Heath Organisations (WHO) has mentioned, should not be treated like any other products or services. It should not be dealth with as though it is a business commodity on sale on the market but an essential to the survival of the community. Therefore, laws to regulate are important as businessman will always be businessman trying to make profit out of everything and not looking after the need and welfare of the community. If businessman starts to take over the health sector, we can expect dying, eroding, poor and unproductive community to start its stage as being healthy is no longer a basic essential but a commercialized choice. The health of the people will no longer be looked after by the highly skilled and trained professionals but a skilled and highly skilled businessman who expertise in making the unnecessary a necessity and making a commercialized decision such as refusal to treat the condition in order to have a long repeating customer even at the cost of death of such customers as their welfare is not their main concern, your spending ability is. Therefore the laws are important to curb these. This will also means public health awareness is also important to educate and shortening the gaps of knowledge. By informing and teaching the public about health, they will make more appropriate choices while denying businessman into manipulating the media and preventing misleading information to reach the innocent community. Despite all the good rating and performance when compared to the other country, as can be seen in the argument above, we are still very far from being able to say that health is not an issue in the country. A lot of factors need to be solved in order to achieve an ideal health heaven in Malaysia. However, the factors mentioned are also a challenge in itself as the politics, the nature of the health business and the ability or technology available in the country is still lacking.

However, if we can identify the key areas and challenges, with the right attitude and determination, all these can be easily changed. As the old saying, a journey of a thousand steps starts with taking one step ahead.