3.6.1 What Went Well?

• The provision of healthcare can be an important factor not only for the improvement of health status but also for the quality of human capital, its productivity and the alleviation of poverty.

• Poor people cannot afford to pay for health services; for them, services need to be free of charge.

• Market mechanisms did not meet the health needs of most of the population, especially those in rural areas, and public intervention was required.

• Social change, urbanisation and economic development alleviate some health problems but give rise to others.

3.6.2 What Did Not Go So Well?

• Fragmentation of responsibility between various agencies significantly impacted health. Recognition and management of fragmentation varied.

• The health system is constrained in its ability to deal with some politically charged issues, such as undocumented migrant groups.

3.6.3 Trends and Challenges?

The continued growth of the private health sector and rising health expenditure will be a challenge for the future development of healthcare.

4.2.1 Drivers and Contexts

At independence, about 75% of the population lived in rural areas, and almost half the population lived in poverty (Reference Mohd Ashad and ShamsudinMohd Ashad & Shamsudin, 1997). The ethnic composition reflected the urban–rural divide, with ethnic Malays being largely rural, ethnic Chinese largely urban and ethnic Indians largely in the rubber estates. Maternal and child mortality was high, nutritional status was poor and the incidence of infectious diseases was high. Table 4.1 provides a glimpse of Malaysia’s health status at independence and its evolving status during the subsequent 30 years.

Table 4.1Health indicators in Malaysia, 1957–1990

Source: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d..

¹ 1956–1960

² 1966–1970

The PHC system developed for Malaysia was built on the healthcare system inherited from the British colonial system. It consisted of outpatient clinics attached to hospitals, a few dispensaries and infant welfare centres provided by the government, and private sector clinics operated by doctors (general practitioners, or GPs). Almost all of these services were in urban areas. This healthcare system evolved from the requirements of the expatriate governing staff, that is, the more educated and affluent urban population.

The predominantly rural population depended on practitioners of traditional medicine, while workers in the larger rubber estates depended on estate clinics provided by employers. However, four years prior to independence, the country introduced a service to serve the rural population, which evolved into the Rural Health Service (RHS) in 1956, just before Malaysia gained independence (Reference RudnerRudner, 1972; Reference IsmailIsmail, 1974; Reference Wong, Ng and SuJ. H. W. Wong et al., 2019).

Independence brought into power an elected coalition of ethnically based political parties, led by the ethnic Malay political party. Unsurprisingly, the political focus shifted to prioritise rural communities to reflect the location of strong Malay support. The major thrust of development was to achieve socio-economic transformation by developing the country’s basic rural infrastructure, modernising agricultural production in rural areas and improving education and health (Federation of Malaya, 1960; Reference RudnerRudner, 1972; Reference Lee and LeeLee & Lee, 2017). Infrastructure development was an integrated approach that included rural roads, drainage and irrigation, schools and clinics (Reference Mohd Ashad and ShamsudinMohd Ashad & Shamsudin, 1997). Planning and development was co-ordinated by the Economic Planning Unit in the Prime Minister’s Department, and the progress of all elements within each administrative district was monitored in an integrated fashion through a ‘Red Book’ that commanded the attention of politicians and civil service administrators at national, state and district levels. The RHS was a major component of this integrated development, such that a district would receive an integrated package that increased physical access to basic education and healthcare, while parallel initiatives addressed its economic needs.

4.2.2 The Rural Health Service

The RHS was government funded. A basic RHS unit served 50,000 population. It consisted of a main health centre (MHC), 4 sub-centres (HSC) and 20 satellite midwife clinics, each with an attached residential facility for the midwife (MCQ). This basic unit was designed to provide ‘integrated curative and preventive health services’ (Reference JayasuriaJayasuria, 1967). Table 4.2 illustrates the services and notional staffing pattern of the basic RHS unit. The number of rural health facilities increased significantly between 1960 and 1980 (Table 4.3).

Table 4.2Rural Health Services and notional staffing pattern

Source: Reference Wong, Ng and SuJ. H. W. Wong et al., 2019.

Table 4.3Number of rural health facilities in Peninsular Malaysia

Sources: Prime Minister’s Department, 1971; 1976; 1981; Reference IsmailIsmail, 1974.

¹ Including clinics already converted to community clinics (klinik desa).

During the first 10 years, the major challenges included difficulty in matching the rate of facility construction with that of population growth, inadequately trained staff for facilities that had been completed, and prevailing cultural beliefs and taboos that hindered service utilisation. After 15 years of development, by 1975, the facility-to-population ratios showed that only 50% of population coverage targets had been achieved. A community survey showed that 24% of the rural villages in the survey areas were ‘underserved’ (Reference NoordinNoordin, 1978). To increase access, the static facility-based services were supplemented with mobile clinics-cum-dispensaries that travelled by road or river, and dental clinics funded by the government, all providing free access to the population (Reference IsmailIsmail, 1974; Reference Tate Abdullah, Khoo and GabrielTate Abdullah et al., 2005). These teams visited remote villages and provided a PHC package consisting mainly of curative, MCH and immunisation services periodically.

4.2.3 The Influence of the Alma Ata Declaration on the RHS: Community Mobilisation, Enhanced Intersectoral Co-ordination, Referral Systems

By the time of the Alma Ata Declaration (1978), Malaysia had already adopted many of the basic concepts of the Declaration. The serving Director-General of Health, Dr Raja Ahmad Noordin, stated: ‘Malaysia viewed PHC as an extension to its existing health care services’ (Reference NoordinNoordin, 1978). The major contribution of Alma Ata was to provide a fillip for the conceptual enhancement of PHC services by spurring the introduction of community mobilisation, enhancing inter-sectoral co-ordination and strengthening referrals to and support from hospitals (secondary healthcare) (Box 4.2).

Dr Noordin spearheaded community mobilisation to make it an integral complement to expanding health services. Additionally, facility expansion was accelerated such that the RHS configuration was modified to extend the coverage of the basic unit to serve a population of 20,000. Staffing profiles changed accordingly. Emulating the successful experience in one state (Sarawak), midwives were upgraded to become rural (community) nurses and given a wider scope of responsibility (Chapter 8). Accelerated training of nurses and midwives enabled rapid upgrading of the quality of services. Simultaneously, community mobilisation took several forms, with active efforts to encourage communities and families to promote health, prevent illness and utilise health services appropriately. Health staff became focal points for organised community efforts, as exemplified in the rural sanitation programme (Chapter 7). Nursing and midwifery staff gained entry to male-dominated village development committees by working in partnership with sanitation staff. This approach enabled them to promote safe childbirth by sensitising communities to the danger signs in childbirth and pregnancy and encouraging the acceptance of prompt medical intervention to save the lives of mothers and babies. Pregnancy care included supervision of childbirth at home by trained, certified midwives, followed by 10 days of daily postnatal home visits that enabled the visiting health staff to build a rapport with the family and the community while establishing breastfeeding and healthy nutritional habits (Reference Pathmanathan, Liljestrand, Martins, Rajapaksa, Lissner and de SilvaPathmanathan et al., 2003).

Inter-sectoral co-ordination became a part of service delivery as well as infrastructure development. Child health included growth monitoring, oral re-hydration techniques, breastfeeding, immunisations, food supplementation, female literacy and family planning. Partnership with rural women’s development programmes enabled health staff to raise awareness of hygiene and nutrition. Health topics were integrated into school curricula through interagency co-ordination between the Health and the Education Ministries, and school visits by nurses and dental nurse teams brought basic screening, referral and simple treatment to the doorstep of the expanding school-enrolled population. Partnership with traditional birth attendants (TBAs) reduced unsafe childbirth while giving the TBAs a continuing role in supporting birthing women (Reference Pathmanathan, Liljestrand, Martins, Rajapaksa, Lissner and de SilvaPathmanathan et al., 2003). Nutrition demonstration sessions by nurses in rural clinics gained popularity. The Applied Food and Nutrition Programme, implemented in districts with high levels of malnutrition, is an example of a partnership with the agriculture, rural development and women’s empowerment initiatives.

Regional disparities in social status and poverty led to targeted poverty reduction programmes. These programmes included initiatives for better access to healthcare and for addressing childhood malnutrition in disadvantaged areas. The prevalence of childhood malnutrition was used as a surveillance tool, while the prevalence of undernourished children was a criterion for identifying low-income families to receive food supplementation as well as assistance with education, housing and employment (Economic Planning Unit, 2004).

Another influence of Alma Ata was to highlight the health needs of remote populations, including the indigenous people (Orang Asli), who had limited access to transport to and communication with healthcare facilities. Mobile teams had to travel over unsealed roads, by river and on foot to serve these communities periodically.

The effectiveness of these measures, in combination with the broader socio-economic development issues discussed in Chapter 3, is evident, for example, in the rising levels of childbirth attended by skilled birth attendants, immunisation coverage and declining maternal and child mortality (Table 4.4) (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). The proportion of deliveries by trained personnel increased from 77.2% (Peninsular Malaysia) in 1975 to 95.2% (Malaysia) in 1996 (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). Referral systems were established particularly for maternity and for infectious diseases such as malaria and tuberculosis (TB). When nurses based in rural clinics referred patients with obstetric problems to hospitals, these patients were given priority and prompt attention. Pregnant women and young children carried personal health cards displaying their pregnancy and healthcare information, thereby facilitating information exchange between PHC and secondary levels of care (United Nations Development Programme, 2005; Reference AwinAwin, 2011). The major communicable disease control programmes established similar referral systems (Chapter 6). The parallel development of rural roads and the provision of ambulances stationed at the MHCs facilitated the movement of referred patients, thereby supporting the referral system. This service delivery system in turn enhanced the credibility and acceptability of health services for the rural population. Senior obstetricians who served in public sector hospitals during that period freely attributed the decline in maternal death to the sterling efforts of rural-based nurses and midwives in identifying complications of pregnancy and childbirth and getting patients to hospital in time for effective interventions (Reference Pathmanathan, Liljestrand, Martins, Rajapaksa, Lissner and de SilvaPathmanathan et al., 2003).

Table 4.4Percentage of institutional deliveries and immunisation coverage, 1970–1990

Source: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d..

¹ Peninsular Malaysia only.

4.2.4 PHC in Urban Areas

4.3.1 Drivers of Change

Economic growth continued over the following 30 years, although there were a number of setbacks, including the Asian financial crisis. The population became increasingly urban, reaching almost 70%, and the proportion of teens and young adults increased, followed by an increase in the number of elderly people (Chapter 3). Lifestyles and health-related behaviour, particularly around food and physical activity, began to change. For example, during the 1990s, tobacco smoking and drug addiction were major concerns, while in the 2000s, the obesity epidemic took centre stage (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). As people became increasingly well-connected with the world through media and travel, public expectations of healthcare increased.

Rising healthcare costs competed with other priorities in the national budget and increased pressure on the health sector to consider alternate approaches for healthcare financing (Chapter 9) and cost containment. The voices of civil society became stronger, with a growing dichotomy between conservative and liberal value systems. This generated debates and tension on many health-related issues, such as reproductive health and HIV/AIDS. Additionally, international pressures, first towards achieving Millennium Development Goals (MDGs) and subsequently re-aligning towards Sustainable Development Goals (SDGs), influenced national health goals (Chapter 6, Case Study 6.1).

All of these interacting forces were drivers that influenced health policy and the evolution of PHC, first towards the provision of a greater range of services to cater for new and emerging needs; second towards better integration between services. Integration and co-ordination were needed to remove institutional barriers between the multiple healthcare services that catered to any particular family and to focus on providing health services to meet the needs of people within their families and communities. The rapid urbanisation also required different modalities from rural settings for the provision of integrated PHC.

The Seventh Malaysia Plan (1996–2000) marked a change for PHC with the establishment of a new PHC division in the Ministry of Health (MoH) (Economic Planning Unit, 1996). The evolving PHC services during this period had two major characteristics. First, in the public sector (mainly MoH services), there was convergence of the hitherto separate services for promotional-cum-preventive health provided at health centres and the curative outpatient services provided by MoH hospitals and health centres. Second, in the private sector, serious stresses emerged in services provided by GPs, associated with issues of financing and competition from public-sector clinics and by specialist practitioners who also provided primary care (Chapter 4, Case Study 4.2).

4.3.2 PHC Services in the Public Sector

The overarching goal of the public sector was to achieve equitable access to more comprehensive primary care. Three threads of interlinked thrusts towards this goal are discernible, namely:

• Expanding the scope of PHC services to encompass additional age groups and health needs.

• Integrating preventive-cum-promotional services with curative services to address segmentation and compartmentalisation and provide seamless care for individuals, families and communities.

• Improving the quality of services to respond better to expectations in the community and professional groups.

4.3.2.1 Expanded Scope of Preventive PHC Services in the Public Sector

During the 1990s, responding to demographic and morbidity trends, the preventive and health promotional services provided by health centres expanded to include additional age groups (adolescents, adults, women’s and workers’ health, the elderly, children with special needs) and health problems, such as mental health and screening for iodine deficiency and glucose-6-phosphate dehydrogenase (G6PD) deficiency, while the national childhood immunisation programme expanded to include measles, mumps and diphtheria, and Haemophilus influenzae (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.).

The clinic-based services were complemented by community-based programmes. The nutritional surveillance of children and pregnant women conducted in 1988 provided valuable input to the national poverty reduction initiatives and rehabilitation efforts (National Coordinating Committee on Food and Nutrition, 2006). The Food Basket Programme (also known as the rehabilitation programme for malnourished children) for children with poor nutritional gain continued to reach out to poor communities (National Coordinating Committee on Food and Nutrition, 2006). Clinic-cum-community services were also initiated to support anti-tobacco smoking efforts, which included smoking cessation clinics. The health clinic advisory panels (panel penasihat), with local community representatives, worked with health staff on four major areas: healthy ageing, advocacy for immunisation, dengue control, and diabetes and overweight management (Reference Mustapha, Omar, Mihat, Noh, Hassan and Abu BakarMustapha et al., 2014).

Simultaneously, the hitherto rural health services gradually increased their coverage to include urban areas in response to demands from local authorities that had little interest in providing services that did not generate revenue. This required organisational re-structuring, including the transfer of authority, staff and some physical facilities from the local authority to the national MoH, particularly in the metropolitan cities of Penang, Melaka and Kuala Lumpur. It also paved the way subsequently for easier integration of preventive and curative services.

Gaps in and limitations to expansion.

Financial and human resources constraints limited some of the service expansion. For example, cervical cancer screening had already been planned to incrementally cover larger sections of the target age group, but laboratories could not cope, and the turnaround time was slow. Screening reached only 6% of eligible women (aged 20–65 years) between 1996 and 2003 (Figure 4.1) (Ministry of Health Malaysia, 2005), and follow-up call services were inadequate (Reference Wong, Wong, Low, Khoo and ShuibL. P. Wong et al., 2008). Also, other components of the health system interacted with PHC services in the public sector to initiate, facilitate or limit the expansion of PHC services. Examples are summarised in Box 4.4.

Figure 4.1

Pap smear slides taken and coverage in Malaysia, 1994–2003.

Source: Ministry of Health Malaysia, 2005.

Box 4.4Influence of other health system components on PHC: summary of illustrative examples

Examples of Limiting Factors

Finance: Dictated the speed and influenced the scope of expansion. While new programmes were added, some existing programmes, such as family planning and cervical cancer and breast cancer screening programmes, failed to gain traction.

Workforce: Upgrading the competencies and recruitment of new categories with different competencies needed, such as finance, training and managerial support. For example, the lack of trained staff hampered the ability to provide rehabilitation, occupational therapy, home visits and home care nursing services for the elderly.

Examples of Enabling Factors

Medical products and technology: Additional affordable vaccines (measles, mumps and rubella (MMR), hepatitis B, human papillomavirus (HPV)) and the availability of simple field tests (G6PD and hypothyroidism screening) enabled the expansion of services. Staff training and financial support enabled this expansion.

Health information: Nutritional surveillance identified anaemic pregnant women and malnourished children and enabled the provision of food baskets for them as part of multi-sectoral poverty reduction; Teleprimary Care enabled better management of diabetes and hypertension by providing data for targeted monitoring and follow-up.

Governance: Community mobilisation and inter-sectoral co-ordination supported strategies for reducing disease risk factors. Grants were allocated for promotion, prevention, early screening and rehabilitation care. Illustrative examples are the mobilisation of teens through peer-to-peer counselling within school communities for targeted purposes such as tobacco smoking and drug use (PROSTAR) and for more general behaviour change purposes such as healthier lifestyles (Doktor Muda) (Ministry of Health Malaysia, 2005). New legislation established standards for care, including care of older people in private healthcare facilities, and also mandated the sale of iodised salts in districts with high risk of iodine deficiency disorders.

Sources: Government of Malaysia, 1998; 2012; 2018; Reference Lee and LeeMinistry of Health Malaysia, 2003; 2007; 2012; 2013.

4.3.2.2 Integration of Preventive and Curative Services in the Public Sector

Prior to the mid-1990s, curative PHC services were provided by:

• Outpatient departments (OPDs) of public sector hospitals and some satellite clinics for free or for a nominal charge.

• Public sector health centres and dispensaries, also free or for a nominal charge.

During the 1990s and early 2000s, two related organisational changes within the MoH led to better integration of preventive and curative services. First, the implementation of a policy decision to move OPDs out of hospitals and into health centres began in the late 1990s and continued incrementally over the next decade. Second, this move was followed by the re-organisation of services in the health centres to better serve the goal of developing people-centred PHC.

Transfer of OPDs.

Historically, hospital OPDs primarily catered for acute episodes of illness, rarely providing health prevention or promotion, and were not geared for the continuity of care essential for non-communicable disease (NCDs). Conversely, health centres had separate arms – the family health arm had good competence for providing preventive and health promotional services for family health aimed at clients in various phases of the life cycle (pregnancy, childhood, adolescence, old age), including individuals, families and communities on a long-term basis. However, the outpatient arm of the health centres mainly provided for walk-in patients. The utilisation of OPD services evolved, with the health centres gradually overtaking the hospital OPDs in terms of volume of utilisation (Figure 4.2).

Figure 4.2

Trends in the utilisation pattern of OPDs.

Source: Suleiman and Jegathesan, n.d.

Additionally, by the late 1990s, the proportion of patients with illnesses such as hypertension and diabetes, which require long-term management, was increasing. Meanwhile, public sector hospitals had difficulties managing outpatient services (OPDs), as their focus was mainly on secondary and tertiary care. Therefore, a policy decision was implemented to transfer OPDs from hospitals to health centres.

Re-organisation of health services.

The outpatient services in health centres were re-vamped to cater to the integration of preventive and health promotional services with illness management (Economic Planning Unit, 1996). The health centres adopted a new approach that integrated basic PHC concepts in addressing the continually expanding initiatives required to deal with NCDs. Box 4.5 summarises the concepts involved, and the illustrative case study on REAP-WISE (Reviewed Approach: Wellness, Illness, Support Services, Emergency Information) elaborates on the initiative. Imaging, laboratory and pharmacy facilities were upgraded progressively as staff and physical infrastructure became available (Economic Planning Unit, 1996; 2001). Communication between primary, secondary and tertiary care was strengthened, and information systems were upgraded to include electronic personal medical records that facilitated the integration of information from the various services that catered to each patient and family (Economic Planning Unit, 2001).

Box 4.5The journey towards integration

The health centre services renewed the PHC concept with a new approach to accommodating its additional services, namely:

1. 1. Preventing and reducing disease burden by treating the ill, managing those with risks and preventing the onset of preventable risks.

2. 2. Enhancing healthcare delivery for fast access to safe and high-quality services with greater comfort in a hassle-free environment.

The wellness focus covers the life-course from antenatal to child and geriatric age for early identification of and management of medical conditions. All new activities for wellness are mapped against age group needs. Teams oversee policy development for the collective activities for each age group in order to integrate workflow processes, accounting for monitoring indicators, quantity and quality of human resources required, the diagnostic equipment, pharmaceutical requirements, and physical space for these activities. These workflow processes are then phased in at clinics nationwide.

(Reference Jaafar, Suhaili, Mohd Noh, Zainal Ehsan and LeeJaafar et al., 2007)

Gaps and limitations to the integration and re-organisation.

This re-organisation process required the re-allocation of budget and human resources between hospitals and health centres, and it also required re-engineering health information systems to provide real-time access to patient information for care providers at primary and secondary level. Table 4.5 illustrates the gaps and challenges in integration and re-organisation as well as the action taken to address such challenges.

Table 4.5Gaps and challenges and action taken in integrating preventive and curative services

Sources: Economic Planning Unit, 1996; Reference AwinAwin, 2003; Reference Awin2004.

4.3.2.3 Focus on Improving Quality of Care

During the late 1980s, the rising expectations of the public, as well as the strong commitment of professional leaders to quality of care, led to the introduction of a variety of quality improvement initiatives in the MoH (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). The scope of quality improvement was defined as including technical quality of care, client satisfaction and resource utilisation. This compares well with the statement 30 years later by the Organisation for Economic Co-operation and Development (OECD), the World Health Organization (WHO) and the World Bank defining the ‘measurable characteristics of quality as effectiveness, safety, people-centeredness, timeliness, equity, integration of care and efficiency’ (OECD et al., 2018). The key initiatives included raising the levels of competence in the PHC workforce and introducing systematic monitoring of quality followed by measures to identify and address systemic weaknesses that contributed to inadequate quality.

Higher levels of competence in the PHC workforce.

Medical officers, who were the front-line providers of care for illness episodes in health centres and OPDs, had no post-graduate or vocational training and had limited ability to manage more complex and chronic conditions, such as NCDs and mental illness. Years of effort by professional leaders (Reference RajakumarRajakumar, 1984) culminated in universities offering a new post-graduate training programme of Family Medicines, while the MoH created a new cadre of specialist: the family medicine specialist (FMS). This new category of FMS was expected to provide leadership in upgrading the quality of primary care services that included a more holistic approach of seamless care for health promotion, disease prevention, illness management and rehabilitation for individuals and families (Reference AwinAwin, 2004).

In tandem, the competencies of nurses and medical assistants were upgraded. The local production of allied health professionals, such as diagnostic radiographers, medical laboratory technologists, physiotherapists and dieticians, was stepped up with a higher level of qualifications and was modernised through integrated training approaches. Previously, the services of these allied health personnel were available only in hospitals, but now they were added to PHC teams (Ministry of Health Malaysia, 2006).

Quality monitoring and improvement strategies.

Hitherto focused on monitoring and improving ethnic and regional disparities in equitable access to care and health outcomes, PHC services added new dimensions to their performance monitoring (Box 4.6). Table 4.6 shows illustrative examples. The conglomerate of activities created a ‘bottom–up’ quality culture within the organisation.

Table 4.6Quality monitoring and improvement: examples of experiences in primary care

Sources: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d.; Ministry of Health Malaysia, 2004.

Box 4.6Dimensions of quality that were monitored and improved

• Workforce skill levels and competence

• Outcomes of prevention and management of illness

• Client satisfaction

• Resource utilisation

4.3.3 PHC Services in the Private Sector

In the private sector, doctors (GPs) provide ambulatory non-specialist curative services on a fee-for-service basis. In the 1980s and 1990s, as rural to urban migration increased and the economy improved, the size and utilisation of the private sector increased rapidly (Figure 4.3).

Figure 4.3

Estimated outpatient visits to clinics per capita per annum, Malaysia, 1930s–2000s.

Note: Private outpatient refers to outpatient visits to both hospitals and clinics.Source: Health Policy Research Associates et al., 2013.

Box 4.7 summarises the characteristics of GPs, who provide about half of ambulatory care in Malaysia. Despite their importance in the health sector, governance and financing arrangements result in GPs having few incentives to provide prevention and promotion services. Their fee schedule is per visit and has not been adjusted for inflation over the past 15 years (Reference MaharajahMaharajah, 2018). It is not geared to reward the time and effort spent on health promotion. For many GPs, the fee is so low that it is not financially sustainable, and they rely on the sale of medications to maintain financial viability. Patients are free to move between doctors; doctor-hopping is frequent and therefore continuity of care could be compromised, and it can be difficult to build a trusting and long-standing relationship between providers and clients and their families. Additionally, there is no restriction on patients seeking primary care from doctors who practise as specialists in any discipline in the private sector. Therefore, specialist doctors are in direct competition with GPs.

Table 4.7Top three reasons for encounters in public and private clinics

Source: Clinical Research Centre, 2014.

A Quality and Costs of Primary Care (QUALICOPC) study showed that three-quarters of the patients who visited private clinics reported that they did not have a primary doctor to follow up on their condition (Reference Sivasampu, Mohamad Noh, Husin, Wong and IsmailSivasampu et al., 2016). Health information systems are underdeveloped. Few patients’ medical records are computerised and there are no incentives for recall and follow-up of patients who require long-term management. There is no systematic monitoring of the quality of care (Reference Sivasampu, Mohamad Noh, Husin, Wong and IsmailSivasampu et al., 2016). In contrast, for example, in Australia, there are targeted incentives for private sector primary care providers to support immunisation and cervical smear testing and for installing information technology (Reference KhooKhoo, 2002).

Additionally, GPs face serious economic challenges arising from the introduction of third-party administrators (see Case Study 4.2). On top of that, medical insurance schemes generally do not cover ambulatory care. In a recent survey, 70% of GPs interviewed cited as serious threats market competition from community pharmacies, and 55% cited market competition from the public sector 1Malaysia clinics (Reference KennyKenny, 2017).

4.3.4 Traditional and Complementary Medicine

TCM is responsible for about 6% of expenditure on ambulatory care. For the first 50 years after independence, the allopathic healthcare system adopted an attitude of peaceful co-existence with TCM, responding only to curb practices that were known to be dangerous to health. This chapter is hampered because there is little empirical evidence of TCM practices or their outcomes. During the last 10 years, initial efforts were directed at establishing a database of practitioners and practices and developing regulations to set standards for practitioners (Reference Mahmud, Tahir, Ida Farah, Ami Fazlin, Sondi and AzmanMahmud et al., 2009; Division of Traditional and Complementary Medicine, 2017). These were the first steps in integrating TCM into the country’s PHC system. Case Study 11.1 provides insights into some of the challenges.

4.3.5 Outcomes of PHC in the Public and Private Sectors

Access, satisfaction, quality and continuity of care.

A QUALICOPC study showed that patients generally did not perceive barriers to access (physical and financial) to care and were satisfied with the care they received at both public and private clinics (Table 4.8) (Reference Sivasampu, Mohamad Noh and ChinSivasampu et al., 2015; Reference Rajakumar2016).

Table 4.8Access to and satisfaction with primary care

Sources: Reference Sivasampu, Mohamad Noh and ChinSivasampu et al., 2015; Reference Rajakumar2016.

The large majority of doctors in both public and private clinics were reportedly involved in health promotion as part of their normal patient contact, though not in group sessions (Table 4.9).

Table 4.9Doctors reporting involvement in health promotion during routine patient encounters

Sources: Reference Sivasampu, Mohamad Noh and ChinSivasampu et al., 2015; Reference Rajakumar2016.

Referral linkages with secondary and tertiary care were not strong (Table 4.10), particularly in terms of feedback from secondary to primary care level and in horizontal communication between primary care providers.

Table 4.10Referral experiences reported by doctors

Sources: Reference Sivasampu, Mohamad Noh and ChinSivasampu et al., 2015; Reference Rajakumar2016.

¹ Within 1–14 days.

² Delayed by >14 days.

As the doctor-shopping phenomenon was observed and there was a lack of longitudinal continuity at private primary care clinics (Reference Sivasampu, Mohamad Noh, Husin, Wong and IsmailSivasampu et al., 2016), it is not surprising that significant differences were noted in aggregated performance indicators of quality of care between public and private sector primary care, with the public sector surpassing the private sector (Table 4.11).

Table 4.11Clinical outcomes for the management of diabetes and hypertension

Source: Ministry of Health Malaysia & Harvard T. H. Chan School of Public Health, 2016.

¹ MHSR (Malaysia Health Systems Research) analysis using NHMS (National Health and Morbidity Survey) 2015 data. Fasting blood glucose of 4.0–6.1 mmol/L or non-fasting blood glucose of 4.4–8.0 mmol/L.

² MHSR analysis using NHMS 2015 data. Target blood pressure of ≤140/90 mmHg.

³ MHSR analysis using Teleprimary Care data, which relates only to care at MoH clinics.

n.a. – not available

4.5.1 What Went Well?

• PHC is part of rural development; PHC benefits from the development of education and communication and contributes to rural development.

• The cornerstone of PHC is equitable access to services; close linkages with secondary care and community mobilisation are key; urban settings require different modalities from rural settings in the provision of integrated PHC.

• Appropriately trained and supervised allied health workers provide low-cost, high-impact PHC.

• Systematic monitoring, focused on identifying and resolving systems issues rather than creating a blame culture, improved quality of care.

4.5.2 What Did Not Go So Well?

• The dichotomy between the public and private sectors in terms of financing and governance continually generates challenges that have not been addressed adequately.

• The rigid structure of the civil service (including the public sector health services) and the fee-for-service mechanisms of the private sector continue to be major constraints in the development of PHC.

4.5.3 Trends and Challenges

Epidemiologic, demographic and technological trends will require flexible adaptive responses from PHC.

5.2.1 Socio-demographic Pressures and Political Forces

After independence, political and community forces dictated development. Policies aimed to improve health and social services and reduce disparity between regions and ethnic groups (Prime Minister’s Department, 1961) (see Chapter 3). For secondary care, these policies translated into measures to increase access to secondary care by upgrading existing hospitals where necessary and providing hospitals in districts that had none. Each hospital provided inpatient as well as outpatient (ambulatory) care. Together with rural health centres and dispensaries that also provided outpatient services (see Chapter 4), outpatient services provided first-contact curative care. A report by the then Director-General of Health credits the ‘widespread establishment of outpatient departments and referrals to hospitals’ with ‘provoking awareness of the rural people of the benefits of modern medical treatment’ (Reference IsmailIsmail, 1975).

5.2.2 Hospital Services Supported PHC

Even before Mahler’s historic 1980 address, the Malaysian district hospitals were first-line referral facilities. They provided support for PHC through secondary care for patients referred from the national disease control programmes, such as those for malaria, tuberculosis (TB) and leprosy (see Chapter 6), and the rural health services, particularly for pregnancy, childbirth and illnesses of childhood (see Chapter 4). The staff of these hospitals were mainly nurses, midwives, medical assistants and junior doctors who were able to address emergencies, minor surgery, childbirth and its simpler complications, and the management of illnesses that required hospitalisation. However, the hospitals had neither the staff and the operating theatres for surgery nor the laboratory and imaging facilities for more complex secondary care. However, the district hospitals did have ambulances that provided free transport links on the one hand between district hospitals and state-level hospitals that had more sophisticated facilities and on the other hand between hospitals and health centres that provided PHC. These ambulances ferried patients, staff and laboratory samples and were crucial in providing the referral link between primary and secondary levels of care.

State-level hospitals provided, at a minimum, specialist care in internal medicine, surgery, obstetrics and gynaecology, paediatrics, and anaesthesia, with appropriate support services (Reference IsmailIsmail, 1975). During this period, several existing, dilapidated state-level hospitals were re-built or refurbished. The government highly subsidised medical care in the public sector hospitals and therefore imposed only a nominal charge on patients at the point of care (see Chapter 9).

The development of STC required the production of a sufficient workforce of doctors and nurses. However, the number of doctors produced was small, as there was only one local medical school (later three) (see Chapter 8). Furthermore, there was no local facility for postgraduate specialist training for Malaysian doctors, and very small numbers were sent abroad annually for training, mainly to the United Kingdom. On their return, they slowly replaced the expatriate specialists and provided specialist services and leadership for the different clinical disciplines. However, the rapid production of nurses and assistant nurses (see Chapter 8) facilitated district hospitals in providing selected forms of secondary care services, and this, to some extent, compensated for the much slower production of doctors. Working alone or with doctors, medical assistants provided secondary care for communicable diseases and other common ailments that did not require specialist care. Nurses who had an additional year of midwifery training became nurse-midwives and, assisted by trained midwives, managed uncomplicated childbirth in all hospitals. The number of district hospitals increased, as did hospital beds for TB, leprosy and childbirth. The hospitals also provided support for the rapidly developing primary health care services (Box 5.2).

During the subsequent three decades, advances in medical products and the success of the disease control programmes enabled hospitals to reduce the beds provided for acute communicable diseases (Figure 5.1). Also, improved access to STC for pregnant women contributed to the reduction in maternal deaths and sustained the demand for institutional childbirth. Box 5.3 provides illustrative examples.

Figure 5.1

Evolving profile of types of hospitals, number of TB and leprosy beds, and childbirth in hospitals.

Source: Calculations by author based on data from Suleiman and Jegathesan (n.d.).

The rapid increase in the utilisation of hospitals throughout the country demonstrated the rising demand for STC (Figure 5.2).

Figure 5.2

Utilisation of Ministry of Health hospitals in Peninsular Malaysia, 1970 and 1996.

Source: Suleiman and Jegathesan, n.d.

Although the availability of hospital services increased, they barely coped with the rate of population increase. Fifteen years after independence, the disparity in the availability of STC between the more urbanised West Coast states in the Peninsula and the less developed East Coast states² remained evident (Table 5.1).

Table 5.1Regional disparity in secondary care in different regions of Malaysia, 1972

Source: Calculations by author based on data from Reference Abdul, Gurmukh and MatinezAbdul et al. (1974).

n.a. – not available

5.2.3 Demand for STC Outstripped Supply

Financial and implementation capacity constraints slowed the progress of building new facilities. In addition, the limited production of doctors led to numerous vacancies in medical officer positions. Meanwhile, societal perceptions were changing. Increased access to hospitals led to a rapid increase in demand for STC. By the mid-1970s, public sector hospitals, particularly the larger ones, faced overwhelming demand, leading to overcrowding. A study of the utilisation of public sector hospitals (Institute for Public Health, 1983) delved into the phenomenon. It found that about 50% of medical officer posts were vacant, although nursing posts had fewer vacancies. Medical staff were unable to cope with the workload. About 25% of patients bypassed smaller district-level hospitals to seek care in larger hospitals. The commonest reason reported was the lack of surgical services. Patients were also dissatisfied with ward conditions (Public Health Institute, 1983). Many doctors, frustrated with conditions in the public sector, resigned to become general practitioners in the private sector. This contributed to the continued shortage of doctors in public sector hospitals (see Chapter 8 re. brain drain). Moreover, it exacerbated the difficulty of improving access in the less-developed states in the country.

5.2.4 STC in the Private Sector Began to Grow

In the meantime, the number of local doctors with specialist qualifications increased steadily, and they served under high pressure in the overcrowded larger hospitals. Recognising the strong demand for more comprehensive STC and exhausted by the high pressure of work, several of them resigned from the public sector during the late 1970s and established four private for-profit hospitals in the largest towns on the West Coast. These hospitals began the trend for the growth in private sector STC in response to demands by the more affluent section of the community for more personalised care and better ‘hotel-type’ facilities. By 1980, 4.3% of all hospital beds were in private hospitals.

The few established non-governmental organisation (NGO) hospitals that predominantly served the ethnic Chinese population had close links with Chinese traditional practitioners and provided some traditional Chinese medicine (TCM) services.

Supplementary Table 5-a in Appendix II summarises the interaction between different elements in the health system and the larger ecosystem as they influenced the evolution of STC during the first post-independence phase.

5.3.1 Political, Socio-economic and Professional Influences

During the 1980s and 1990s, the population became increasingly urban, and literacy rates and socio-economic status rose, as did the population’s expectations of healthcare. Many communicable diseases decreased, while non-communicable diseases (NCDs) increased. A dual thrust in health policy governed the development of STC. The first was the continued struggle to improve equitable access to STC. The second was to respond to the rising expectations of the community and of professional bodies to provide higher-quality care, including care that was:

1. a. clinically more sophisticated, with more equitable access to surgical interventions, and

2. b. better quality in terms of

   1. ◦ effective outcomes,

   2. ◦ higher client satisfaction, and

   3. ◦ improved use of resources.

5.3.2 More Sophisticated Clinical Care

Doctors with postgraduate training in specific disciplines had the higher level of competency required to provide comprehensive STC. Specialist training in local universities for doctors began during the 1980s (see Chapter 8) and resulted in the availability of larger numbers of doctors with specialist qualifications and the establishment of a wider range of specialised units in public sector hospitals. This, in turn, triggered the upgrade of laboratory and imaging services and the training of allied health personnel, such as medical laboratory technologists and radiographers, for these services (see Chapter 8). To promote equitable access to specialised medical services, the Ministry of Health (MoH) adopted a regional development approach. State-level and larger district hospitals were categorised into three levels, with Level 1 consisting of five basic medical specialities, Level 2 having six additional specialities and Level 3 consisting of further specialisation within narrow fields of the more general disciplines (such as cardiologists and neurologists within the broader field of internal medicine). Every region in the country had one hospital of Level 3 status and at least one with Level 2 status. The availability of speciality services increased from 12 units per million people in 1970 to 16 units in 1997 (Table 5.2).

Table 5.2Increased availability of specialist care in MoH hospitals, 1970–1997

Source: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d.

¹ One unit was equivalent to one or more specialists in a specialist unit or department.

With the growing numbers and types of specialist qualifications from various universities and countries, professional bodies and the MoH were concerned about safeguarding the standards of competence to preserve the quality of care. This triggered governance actions in the form of the establishment of procedures for credentialing and certifying specialists (see Chapter 8).

The increasing numbers and types of sophisticated clinical services required better laboratory and imaging services. For example, Table 5.3 illustrates that the upgrading of laboratory services in MoH hospitals was linked to the type of specialist services available. The upgraded laboratory services required the appropriate allied health personnel with higher levels of qualifications. Appropriate training programmes and deployment strategies came into place.

Table 5.3Laboratory services increased in sophistication in tandem with the availability of specialist clinicians

Sources: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d.;

Reference Suleiman and Jegathesan² Institute of Medical Research (IMR).

The developments required higher investment and maintenance costs. The rising gross domestic product (GDP) facilitated the financing of these investments.

Figure 5.3 provides a summary of the dynamic interactions in the health system as it moved towards providing more sophisticated clinical services.

Figure 5.3

Dynamics of providing more sophisticated clinical services.

5.3.3 Private Sector

Meanwhile, there was high demand for STC in the private sector, leading to the rapid expansion of hospitals (Table 5.4). In 1997, 70% of private hospitals were small, with less than 20 beds, and several were in buildings not suited for providing quality care (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). Concerned about quality standards, the government enacted legislation (Government of Malaysia, 1998) with stringent standards for physical structure and with corporate and clinical governance, including procedures for monitoring quality (see Chapter 12). Enforcement began in 2006.

Table 5.4Rapid growth of private hospitals, 1980–1996

Source: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d. (data extracted from Ministry of Health Malaysia annual reports 1981, 1985, 1990 and 1996).

n.a. – not available

In parallel, there was high demand for care by the few specialist doctors who had established larger private hospitals since the mid-1970s. Recognising a good business opportunity, corporate entities moved in and bought up the larger hospitals. Corporate ownership led to a change in philosophy. While catering for the demands of the well-to-do who could afford private sector fees, these hospitals now also paid serious attention to profit margins. Their expansion and development plans reflected this change (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). One evident feature was the trend towards the rapid proliferation of higher-cost technology in the private sector as compared to the public sector (Table 5.5). These hospitals were concentrated in the wealthier regions of the country, thereby challenging the objective of equitable development.

Table 5.5Distribution of high-cost imaging technology in MoH and private hospitals, 1997

Source: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d.

¹ Computed tomography (CT): The MoH had one unit per state except for the capital city, Kuala Lumpur, which had four units. Private hospitals had 17 units in Kuala Lumpur and neighbouring Selangor and 10 units in Penang.

² Mammogram: The MoH had one unit per state except Kuala Lumpur, which had three units. Private hospitals had nine units in Kuala Lumpur, four units in Selangor and eight units in Penang.

³ MRI – magnetic resonance imaging.

The MoH initiated health technology assessment (HTA) as a means of rationalising the acquisition of newer technology. The output of the HTA unit provided input into the formulation of policies in the public sector and provided the basis for the development of clinical practice guidelines (CPGs), purchasing decisions, drug regulation and health-related advertisements (Reference Roza, Junainah, Izzuna, Ku Nurhasni, Mohd Yusof and NoormahRoza et al., 2019). However, there is limited information on whether the private sector uses the HTA information for guiding the development of technology.

Box 5.4System observations: shifting the healthcare burden to the private sector

The development of the private health sector in Malaysia is an example of how solutions to health system challenges can create long-term, irreversible changes to the system. Rising demand for more sophisticated medical care in the 1960s and 1970s led to a gap in public hospital capacity as limits in financial and human resources caused capacity to lag behind demand. This demand continued to increase in the 1980s and 1990s, so the rise and rapid expansion of private sector hospitals was welcomed by the public sector. While the private sector alleviates the burden of the public sector in some ways, it has become apparent that it draws medical practitioners, especially specialists, away from the public sector (Figure 5.4). The public sector thus has had to invest further resources and change policies to retain medical practitioners to keep up with healthcare demands.

Figure 5.4

Rising demand for medical care outpaced public hospital resources, creating a gap in public sector capacity (B1). The expansion of private sector hospitals (B2 loop) offered a means of bridging this gap with private sector resources. However, private healthcare has drawn on medical personnel from the public sector, becoming another source of pressure on public sector capacity (R1 loop). This is a well-known system archetype known as ‘shifting the burden’, in which actions taken to address the outcomes of a problem (a gap in hospital capacity) can exacerbate the underlying causes of that problem (public hospital human resources).

Private sector care has become corporatised and supporting structures such as private insurance and medical tourism have been developed, creating a self-sustaining industry. In addition to health workforce challenges, the resulting fragmentation of healthcare providers and financers has created challenging tensions regarding the locus of responsibility for the provision and payment of healthcare.

5.3.4 Quality: Monitoring and Improving Outcomes

In the late 1980s, the government of Malaysia initiated nationwide efforts to improve quality in the public sector. The MoH was one of the agencies that led the way in implementing the national call to action. The National Quality Assurance Programme (QAP) of the MoH spearheaded efforts to instil concern for quality as a culture at all levels of the organisation. It established a system for the explicit measurement of outcomes. This included monitoring performance trends in clinical care, patient satisfaction and better use of resources (physical, time and human resources). Box 5.5 provides illustrative examples.

The thrust for improving clinical outcomes (Figure 5.5) provided a fillip for strengthening clinical governance measures such as the development and use of Clinical Practice Guidelines (CGPs) and for stronger implementation of existing initiatives such as clinical audits and mortality reviews. It also contributed to improving the quality of data for health information (see Chapter 10), particularly in terms of accuracy of International Classification of Diseases (ICD) coding and timeliness of data, as healthcare providers became aware that this had a critical impact on the accuracy of indicators that measured performance.

Figure 5.5

Dynamics of improving clinical outcomes and establishing a quality culture at every level.

The drive for improved outcomes of clinical care led to the establishment of disease registries for selected conditions such as end-stage renal disease (ESRD) and cancer, which are managed largely at the secondary care level. The registries are meant to provide information on disease conditions as well as treatment effectiveness and cost. The National Renal Registry, established in 1993, was a trailblazer, and it monitors trends in the quality, cost and effectiveness of different modalities of care for ESRD (Reference Lim and LimLim & Lim, 2004). It provided the data for a cost analysis that enabled the move to public–private partnership in the provision of dialysis (Reference Lim, Lim, Wong, Ahmad, Singam and MoradLim et al., 1999).

The thrust for better outcomes in patient satisfaction and use of resources (Figure 5.6) stimulated a need for increased managerial competence at all levels of the MoH system (see Chapter 8). It also facilitated the growth of team approaches and the use of health systems research as a management and problem-solving tool. Hospitals won national ‘quality awards’ for improving client satisfaction and reducing waiting times (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). Budgeting systems were modified to provide greater authority to hospital managers to manage funds more flexibly to respond to local requirements (see Chapter 9). However, as the MoH was part of a larger public sector system, there were constraints. The degree of flexibility that could be decentralised was limited due to financial rules and regulations (see Chapter 9). Similarly, as all MoH staff are part of the federal civil service (see Chapter 8), constraints arose. For example, nurses with training and credentials in one discipline had to move to another discipline to further their careers (Institute of Health Management, 2006).

Figure 5.6

Dynamics of improving resource utilisation and client satisfaction.

The thrust for improved resource management extended to strategies for improving the maintenance of building structures and biomedical equipment in public sector hospitals. New posts were created for hospital-based engineers, and maintenance services were outsourced to private contractors, with hospitals retaining oversight of the contractors’ performance (see Chapter 7). Performance indicators of quality applied not only to clinical aspects of care but also to support services.

The quality-improvement measures also strengthened support from STC for PHC services (Box 5.6).

Supplementary Table 5-b in Appendix II summarises the interactions in the health system during the 1980s and 1990s (STC development Phase 2).

5.4.1 Organisational Change

In the public sector, there was a rapid increase in the types of clinical specialist units in hospitals and the types of programme management units at national and state levels. Communication between organisational units deteriorated. For example, communication between hospitals and health centres, between hospital outpatient departments (OPDs) and wards, between departments of different clinical disciplines and between district- and state-level hospitals became more challenging (Reference SuleimanSuleiman, 1999). This carried threats to continuity of care for patients, such as people with diabetes, who required long-term care provided by more than one unit or department. There was an increased risk of worse-than-desired health outcomes.

Furthermore, duplications and missed opportunities could contribute to organisational inefficiencies, resulting in rising healthcare costs. The MoH addressed these threats by adopting a policy to ‘provide seamless health care by enhancing integration’ (Institute for Public Health, 1999). Two structural changes of note occurred. First, OPDs in hospitals were moved to health centres that were better suited to provide seamless preventive, promotive and curative care in ambulatory settings and adopted family and community perspectives in the management of conditions such as NCDs. Chapter 4 discusses this initiative.

The second strategy was the formation of hospital clusters to increase access to specialist care and improve utilisation rates in the smaller hospitals. The smaller hospitals had quite a large proportion of unused beds. During the previous experience in the regionalisation approach to improving access, specialists visited non-specialist hospitals. This proved unsuccessful because the smaller hospitals did not have the facilities or expertise to support specialist care. In the cluster concept, a major hospital that had a wider range of specialities formed a cluster with a few neighbouring smaller hospitals to share financial and human resources and equipment. In addition, there was an initial investment in upgrading surgical facilities in the smaller hospitals. Specialists and their teams from the lead hospital provided specialist services at the smaller hospitals on a visiting basis, negating the need to move patients to the major hospital. There was investment in training to enable staff at the smaller hospitals to provide adequate follow-up care after the team from the major hospital had provided treatment. The pooled budget enabled the sharing of financial and material resources such as drugs, equipment and travel between hospitals. There was shared responsibility for the outcomes of care. Initial assessment indicated that these measures provided relief from overcrowding in the major hospital and increased patient satisfaction and cost–benefit in the management of patients with moderate or serious illness. However, they did not increase utilisation rates in the smaller hospitals. Barriers to sustaining or expanding this initiative included frequent transfer of human resources from the smaller hospitals, thus negating the investment in upgrading capacity, and inadequate recognition of the need for the initial additional investment to prepare smaller hospitals to support specialist services (Institute of Health Management, 2016; 2017). Despite these initiatives, the bed occupancy rates of the non-specialist hospitals remained below 50% (Figure 5.7).

Figure 5.7

Bed occupancy rates in MoH hospitals.

Source: Ministry of Health Malaysia, 2016.

Another aspect was the strengthening of referral systems. Within the MoH system, there were continuing efforts to improve the logistics and communication of referral between primary, secondary and tertiary care levels. This included strengthened governance through the refinement and clarification of procedures, expected standards and technological support, for example, through the telehealth project that enables real-time sharing of patient data between primary and secondary care levels, thereby contributing to quality of continuity of care for patients (Reference AllaudinAllaudin, 2014). However, other major challenges arose from governance features of the health system. For example, patients have direct access to specialist clinics in both the public and private sectors without going through primary care (Reference Yiengprugsawan, Healy, Kendig, Neelamegam, Karunapema and KasemsupYiengprugsawan et al., 2017). This encourages the bypassing of primary care. In addition, in the private sector, it encourages rivalry between primary and specialist care providers, which in turn raises the risk of failure to refer conditions that require higher levels of competency. Additionally, evidence suggests that feedback and referral from STC services to primary care in the public sector is weak (Table 5.6). In larger hospitals in both the public and private sectors, rules for referral between different clinical disciplines have not been established.

Table 5.6Referral experiences reported by doctors in public sector health centres

Source: Reference Sivasampu, Mohamad Noh and ChinSivasampu et al., 2015.

5.4.2 Advances in Technology

Technological advances affected STC profoundly. Two illustrative examples of the influence of technology on the delivery of STC services are telemedicine and day-care surgery.

Day-care surgery.

Medical technology such as advanced anaesthesia and minimally invasive surgical technologies contributed to increasing numbers of day surgeries, for example, cataract surgery, laparoscopy and other endoscopies that require short postoperative monitoring and recovery. The evaluation of day-care cataract surgery has been possible through the National Eye Database, which facilitates the tracking of trends in cataract surgery. It provided evidence that contributed to improvements in techniques and technology, as reflected in practice patterns and outcomes (Table 5.7). An increasing proportion of cataract surgery is being performed as day-care, and visual outcomes have improved, indicating improved quality. The success of the day-care centres for cataract surgery is attributed also to the availability of dedicated, well-trained teams of care providers, including highly trained technicians, nurses, specialists and sub-specialists.

Table 5.7Cataract surgery profiles, 2002 and 2015

Source: Reference Goh, Aziz Salowi, Adnan and Sa’atGoh et al., 2016.

Day-care surgery provides an avenue for controlling costs (Evaluation of Specialist Complex and Ambulatory Care Centre, 2018). The day-care centre approach has also contributed to integrated care, with specialists from various disciplines managing patients simultaneously. For example, endocrinologists managing problematic diabetic patients have simultaneous input from orthopaedic and vascular surgeons.

Figure 5.8

Harnessing technology to improve access to seamless, integrated care.

5.4.3 Governance Challenges Affecting STC

The fragmentation of clinical services is a challenge and occurs in at least at two dimensions of care. First, several clinical disciplines are compartmentalised into sub-specialties. Sometimes, the care provider in sub-speciality case management focuses on managing a particular condition to the exclusion of co-morbid conditions. At STC level, technological advancement necessitates multidisciplinary knowledge and skills and cross-discipline references in managing patients with multiple complex conditions. Care providers require the appropriate skills and attributes to recognise when cross-referral is needed and facilitate seamless cross-referrals. Currently, in Malaysia, the policies regarding intra- and inter-facility referral in both public and private sector clinical networks are weak.

Furthermore, clinicians at the PHC level who refer patients to STC levels of care have difficulties identifying the person or department in the hospital responsible for co-ordinating and facilitating such referrals. This situation is further complicated because patients have the right to an informed choice of providers that best fit their medical needs and financial resources. Many patients prefer to skip primary care facilities in favour of direct appointments at specialist clinics or hospitals, particularly in the private sector.

Another dimension of the fragmentation of STC is evident in the fragmentation between the public and private sectors, each with different payment and governance mechanisms. During the first 40 years after independence, the fragmentation of the Malaysian healthcare sector into the public and private sectors appears to have assisted the national goal of improving equitable use of healthcare (see Chapters 3 and 9). Although the schism created tensions, particularly in the distribution of the workforce, it also enabled the wealthier segment of the population who could afford it to utilise private hospitals, thereby facilitating the public sector to provide for the lower-income groups (Figure 5.9) (Health Policy Research Associates et al., 2013).

Figure 5.9

Composition of inpatient care utilisation in public and private sector by socio-economic status.

Source: Health Policy Research Associates et al., 2013.

However, during the most recent two decades, fresh challenges have surfaced, arising largely from underlying governance structures and financing mechanisms.

5.4.4 Rising Expenditure and Costs in the Private Sector

STC accounts for a relatively high proportion (55%) of total health expenditure (THE) (Table 5.8). Private sector hospitals are responsible for an increasing proportion of THE, while that of public hospitals remains steady. Yet the proportion of discharges/admissions in public versus private hospitals has not changed during the period 2012–17. It is not clear whether the increased private sector expenditure is due to investment in new hospitals, investment in new expensive technology or higher cost of patient care.

Table 5.8Expenditure on and utilisation of public and private hospitals, 2012 and 2017

Source: Ministry of Health Malaysia, 2012; 2018a; 2018b.

¹ 2012 data are reported as admissions, not discharges.

Clients are unhappy with the price of care in private hospitals (Table 5.9).

Table 5.9Client satisfaction with hospital services

Source: Institute for Public Health, 2015.

The rapid increase in high-cost technology experienced in the previous decade continues in the private sector (Table 5.5 and Table 5.10). Are considerations of cost recovery from expensive investments driving costs in private hospitals? In the private sector, there is no overriding guide on technology acquisition. In contrast, reports from health technology assessment guide the acquisition of new technology in the public sector. Furthermore, in contrast to the public sector, no one monitors the outcomes of care and appropriateness of care across the private sector network of hospitals. Therefore, there are no feedback loops to trigger action from the authorities or to modify the behaviour of the providers themselves.

Table 5.10Selected medical technology in hospitals, 2011

Source: Reference Sivasampu, Arunah, Kamilah, Fatihah, Goh and HishamSivasampu et al., 2013.

¹ CT – computed tomography

² MRI – magnetic resonance imaging

³ PET – positron emission tomography

In theory, the public sector could harness the excess capacity of technology in the private sector, and there are examples of small-scale efforts in this direction, such as the purchase of PET (positron emission tomography) and CT (computed tomography) services. Case Study 5.1 on renal dialysis illustrates how imaginative cross-funding between public and private sectors can release private funds for initial investments and facilitate partnership for better utilisation of available private sector healthcare resources. However, this model has not been replicated, suggesting that there are serious barriers, perhaps related to finance and governance.

As there is no social health insurance and individual out-of-pocket payment is the largest source of private sector funding (Table 5.11), no organised entity has the responsibility of influencing rising costs. Private insurers are most likely to protect their own pockets by limiting payouts and passing on additional costs to individuals.

Table 5.11Sources of funds in the private sector, Malaysia, 2012 and 2017

Source: Ministry of Health Malaysia, 2018b.

¹ MCOs – managed care organisations

Managed care organisations (MCOs) increased their participation in managing private sector funds from 0.5% to 4% of private funds over five years (2012–2017) (Table 5.11). This has raised further issues of gaps in governance, as illustrated by Case Study 4.2 on MCOs.

5.6.1 What Went Well?

• STC ability to respond to people’s desire for more sophisticated care and professionals’ desire to provide the best care available effectively and efficiently. Key factors are:

  1. ◦ Human resource production and use (see also Chapter 8).

  2. ◦ Systematic quality improvement strategies.

  3. ◦ Use of technology assessment for production of practice guidelines.

• Investment in strengthening management, and decentralised decision-making.

5.6.2 What Did Not Go So Well?

• Smaller hospitals built in response to public demand for access remain underutilised because of system inability to provide the human and material resources expected by the public.

• Rapid growth of private sector STC affects social efficiency of STC and PHC.

• In private sector STC: Unresolved conflict between the interests of shareholders (of companies owning hospitals) and those of stakeholders (users, providers, public sector STC).

5.6.3 Trends and Challenges

• The rapid growth of technology will require adaptive responses from STC and its support systems (e.g. day-care surgery).

• Increasing medical tourism will have an impact on the health system and the societal view of healthcare.

6.2.1 Socio-economic Development Influenced the Development of Disease Control Programmes

The overall improvement of the country’s socio-economic and living conditions (see Chapter 3) facilitated the successes in controlling CDs. The gross domestic product (GDP) per capita increased substantially, with an annual growth of 7.7% between 1970 and the mid-1980s, improving standards of living for the majority of the population, making them less vulnerable to infectious diseases (Reference Tan, Kwok, Tan, Nagaraj, Tey and ZulkifliTan et al., 1987; UN Country Team, 2005). Significant improvements in roads and transportation made healthcare more accessible.

In addition to economic growth and infrastructure development, social development also progressed. The percentage of women (aged 15–19 years) who attended secondary school increased from 15% in 1960 to 75% in 1980, while the percentage of living quarters with piped water and flush toilets rose from 48% and 18% in 1970 to 68% and 60%, respectively, in 1980 (Reference Tan, Kwok, Tan, Nagaraj, Tey and ZulkifliTan et al., 1987). The increase in women’s education levels as well as improved environmental health contributed to the decline of infant mortality caused by CDs; in particular, vaccine-preventable diseases and food-borne and water borne diseases (Reference DaVanzo and HabichtDaVanzo & Habicht, 1986).

6.2.2 Programmatic Features that Influenced Outcomes

6.2.2.6 Outcomes

The BCG vaccination programme realised its initial objective of providing at least 75% coverage of the susceptible population within a short period (Reference Ismail and MartinezIsmail & Martinez, 1974). The mass survey and treatment campaign with PAM under the yaws control activities also reduced the reported cases from 9,462 in 1958 to 335 in 1968 (Reference LoLo, 1985).

The incidence of most CDs declined dramatically (Figure 6.1). The incidence of TB declined from 151.5 per 100,000 population in 1961 to 56.8 per 100,000 population in 1985 (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.); malaria cases reduced significantly from 150,000 to below 50,000 in the late 1970s, but the goal of disease eradication had yet to succeed fully (Reference Mak, Jegathesan, Lim, Hakim, Rain, Ambu and ChongMak et al., 1992). Yaws and filariasis were no longer a concern; the country had successfully eliminated leprosy in 1994 and achieved polio-free status in 2000 (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). With the increase of childhood immunisation coverage (Table 6.2), the infant and child mortality rates had also declined significantly in 1990 (Table 6.3).

Table 6.2Percentage coverage of immunisation in Malaysia, 1970–2017

Sources: Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.; Ministry of Health, 2010; 2018b.

Table 6.3Infant and child mortality rates, 1957–2017

Sources: Reference JayalakshmiJayalakshmi, 1994; Department of Statistics, 2009; 2011a; Ministry of Health et al., 2015.

The two programmes that failed to live up to their initial promise were those for TB and malaria. Although greatly reduced during the 1990s, TB incidence remained a problem. There were two contributing factors: first, the large concentration of foreign workers from neighbouring countries were a continual pool of infection. Local surveillance and control systems were ill-prepared to detect and manage them (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). Second, the HIV/AIDS epidemic brought with it an associated increase in TB due to impaired immune systems (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). The treatment modalities available at that time and programme strategies were inadequate for addressing this threat. For malaria, although incidence declined significantly, pockets of transmission and endemic levels persisted. There were several contributing factors, including people movement that was difficult to monitor, insecticide resistance, drug resistance and changes in vectors.

Box 6.3System observations: understanding feedback loops through communicable diseases

The role of feedback loops in CDs is well known among epidemiologists. They use stock-and-flow models, such as the susceptible-infectious-recovered (SIR) model, to predict and curb the spread of disease. Successful control of CDs relies on disrupting biological transmission feedback loops via vaccination, quarantine, culling of vectors, etc. The wide acceptance of such models in the health profession provides a useful entry point to many important system dynamics concepts.

6.3.1 The Changing Disease Profile

6.3.1.1 The Rise of Non-communicable Diseases

After the late 1980s, socio-economic development, urban migration, changes in work and lifestyles, and demographic transition to fewer children and more people of working age resulted in an evolving disease profile (see Chapter 3). NCDs such as cardiovascular disease, diabetes mellitus and cancer emerged as major contributors to the disease burdens (Supplementary Table 6.a). There was also a shocking rise in the prevalence of NCD risk factors over the years, as shown in the National Health and Morbidity Surveys (NHMS) (Table 6.4). In 2016, NCDs accounted for 74% of all deaths (World Health Organization, 2018), while NCD-related morbidities and disabilities had increased by 80% between 1990 and 2013 (Ministry of Health Malaysia & Harvard T. H. Chan School of Public Health, 2016).

Table 6.4Prevalence of selected NCD risk factors in Malaysia for adults aged ≥18 years, 1996–2015

¹ Data for population aged ≥30 years.

² Data for population aged 15 years and above.

³ NHMS II definition: respondent who reported to be smoking at the time of the survey.

⁴ Centers for Diseases Control and Prevention (CDC) definition: respondent who reported to have smoked ≥100 cigarettes in their lifetime and smoked daily or some days in the past 1 month.

Sources: Institute for Public Health, 1996; 2008; 2011; 2015; Department of Statistics, 2011b; Ministry of Health Malaysia & Harvard T. H. Chan School of Public Health, 2016.

6.3.1.2 Emerging and Re-emerging Infectious Diseases

Since the 1990s, Malaysia has experienced emerging diseases, including HIV infection, dengue, Nipah virus and severe acute respiratory syndrome (SARS), and re-emerging diseases, including resurgent TB and measles, while malaria persisted in endemic areas, perpetually threatening to spread to other areas. (Table 6.5).

Table 6.5Incidence rate of emerging and re-emerging communicable diseases (per 100,000 population)

Sources: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d.; Ministry of Health 2005; 2010; 2018b.

The first case of HIV was detected in 1986, and by 2017, there were a cumulative 115,263 HIV cases (Ministry of Health, 2018a). Initially confined largely to injecting drug users (IDUs), sexual transmission thereof became more prevalent in recent years and has proved a challenge to control measures. First recognised as a public health issue in 1973, dengue incidence has increased tremendously, from 969 cases in 1973 to more than 100,000 cases, with 200 deaths per year, since 2014 (Ministry of Health, 2016).

The factors contributing to the emergence of new diseases or the resurgence of longer-standing diseases are complex and include population movements and lifestyle changes, globalisation and the movement of goods, adaptive mutations in pathogens and vectors, and environmental changes that facilitate or support changes. Table 6.6 shows the illustrative key features of emerging diseases in Malaysia.

Table 6.6Illustrative examples of the rapid emergence of and varied challenges posed by emerging diseases in Malaysia

Source: Adapted from Reference Tee, Takebe and KamarulzamanTee et al. (2009).

The Nipah virus outbreak in 1998–1999, SARS in 2002–2003 and the H1N1 pandemic influenza in 2009 not only posed an increased healthcare burden but also caused social disruptions and economic loss. Up to 40% of cases, or 105 people, with acute encephalitis (out of 265 cases) died during the Nipah virus outbreak (Reference Looi and ChuaLooi & Chua, 2007), while H1N1 caused 77 deaths (out of 12,307 reported cases) in 2009, the majority of whom were children (Reference SamSam, 2015).

Meanwhile, re-emerging diseases such as TB and measles continue to be a public health challenge. TB cases per 100,000 population declined over 30 years from 350 cases to about 60–68 cases but increased to about 84 cases in the subsequent 30-year period (Ministry of Health, 2016). Similarly, despite a strong childhood immunisation programme, measles increased during the 30 years after 1990, from an incidence of 3.1–5.18 per 100,000 population, and one-third of the cases during the recent 2-year period involved children who had never been vaccinated (Ministry of Health, 2016).

6.3.2 Drivers of Change in the Responses to the Disease Profile

6.3.2.3 Leadership, Governance and Competing Priorities

The examples of cross-sectoral collaboration for NCDs quoted above also provide evidence of the government’s commitment and the influence of leaders from the health sector and of the MoH in shaping policy that transcended several sectors. However, balancing the competing priorities in health with other opportunities for economic growth and development remains a challenge for Malaysia, especially in NCD prevention. Several factors and entities outside of health have considerable influence. For example, food, beverages and tobacco are deemed promising industries for driving growth in the manufacturing sector in the Eleventh Malaysia Plan (2016–20). However, they might not contribute to the promotion of a healthy lifestyle for reducing CDs and NCDs (Economic Planning Unit, 2015). Population health outcomes require multi-actors and sectors to work together to address social, economic and environmental risk factors. There is top-level commitment in the form of a Cabinet-level committee comprised of ministers from various sectors and chaired by the deputy prime minister and several task forces for establishing priorities and developing strategies (Box 6.4).

However, progress in translating the top-level commitment into genuine collaborations across ministries and agencies is slow, especially at implementation level. The MoH faces a continuing challenge to advocate for and create an enabling environment and an integrated approach for implementing multi-sectoral strategic plans. Such plans require the acceptance of roles, responsibilities and incentives for each agency to contribute to disease control efforts as well as for monitoring and evaluation mechanisms to track performance and accountability.

Box 6.4National committee/task force/strategic plan/policy

6.5.1 What Went Well?

• The design of disease-specific control programmes, as far as possible, used existing healthcare delivery systems. They also developed specific competencies in programme management, supervision, monitoring and evaluation, which later transferred to the public health delivery system.

• The health system rapidly developed the capacity for prompt recognition and effective control of outbreaks of new diseases, as knowledge on prevention was insufficient.

6.5.2 What Didn’t Go So Well?

• The health system has had less success in dealing with NCDs and CDs caused by:

  1. ◦ Human behaviour such as migration and drug use.

  2. ◦ The adaptive behaviour of pathogens and vectors compounded by human behaviour, such as antibiotic-resistant microbes and dengue.

6.5.3 Trends and Challenges

The increasing prevalence of diseases whose root causes lie outside the traditional jurisdiction of the health system will require innovative leadership and new approaches.

7.2.1 Examples of Malaysia’s EHS Programmes

Some of the main environmental health programmes that were developed successfully are described in this section.

7.2.2 Factors Contributing to Success

The MoH rightly invested in environmental health programmes early on, which is believed to have significantly contributed to the country’s elevated health status. Other than investment, the hallmarks of the developmental process included leadership from the MoH in initiating and sustaining inter-agency collaboration and co-operation, human resource development and selective organizational strengthening, enactment of legislation and development of guidelines, and strategic involvement of the private sector while the public sector retained responsibility for policy and oversight.

7.3.1 What Went Well?

• Basic rural interventions for water and human waste disposal used

  1. ◦ simple technology,

  2. ◦ strong community participation, and

  3. ◦ allied health staff delivered them effectively using established community structures.

• Higher technological interventions requiring appropriate competencies were

  1. ◦ possible for concentrated urban populations (water, solid and liquid waste management);

  2. ◦ needed for complex issues (clinical waste, radiation);

  3. ◦ under the jurisdiction of authorities outside the health sector and needed inter-sectoral co-ordination.

• The health sector successfully

  1. ◦ acquired and empowered staff with the appropriate competencies;

  2. ◦ provided leadership and assisted, then mentored, other agencies to develop the required competencies and exercise their powers through governance, outsourcing and oversight;

  3. ◦ mobilized private sector finance through outsourcing; and

  4. ◦ gained experience and expertise in outsourcing.

7.3.2 What Did Not Go So Well?

Several issues outside the jurisdiction of the health sector remain problematic, for example, occupational health, air pollution and road traffic accidents.

7.3.3 Trends and Challenges

Climate change is expected to increase the frequency and severity of conditions that will stretch the capacity of the health system

Basic (pre-employment) training.

The training of almost every category of allied health professional was upgraded to college or university level and therefore transferred out of the MoH to the MoE. Within the MoH, structural re-organisation resulted in the MoH changing its focus from strategic planning for the entire health sector to merely planning for its own workforce. Thus a strategic vision for human resource development for health was forfeited. Existing training institutions were re-vamped to become research institutions under the umbrella of the new National Institutes of Health (NIH).

Meanwhile, in the education sector, the number of training programmes for health personnel expanded at an explosive rate, driven by demand from the public as well as by commercial and political forces (Ministry of Health Malaysia, 2016b). Additionally, there was an increase in graduates returning from foreign training programmes, many of them funded by scholarships from the public and private sectors. The demand for nursing had escalated with the growth of hospitals in the private sector as well as demand from other countries, particularly in the Middle East, while the unmet demand for medical doctors was a long-standing issue. The quality of graduates varied greatly (Reference NoorlizaNoorliza et al., 2012). This was particularly apparent in nursing and medicine. The health sector had inadequate capacity to absorb the rapidly increased number of new graduates, with insufficient public health service posts to provide placements for the requisite pre-registration and supervised training of doctors (house officers (HOs)), dentists and pharmacists. Meanwhile, the private sector health services were unprepared to employ fresh, inexperienced nursing graduates. The illustrative case study in this chapter explores the dynamics and impact of the structural challenge in relation to the production and utilisation of medical doctors.

Two underlying systemic issues contributed to the genesis of the problems. Medical, dental and pharmacy education programmes are relatively long (4–6 years). Hence there is a significant time lag between entry into training programmes and graduates seeking entry into the workforce. There was no institutional mechanism for regular timely exchange of critical information between the education and health sectors that would have facilitated pro-active planning taking into account the numbers of entrants and expected graduates. Additionally, institutional mechanisms for joint strategic planning and decision-making are unstable and personality-dependent (Box 8.4) (Reference BuchananBuchanan, 2015).

For the first time, doctors and nurses in the public sector outnumbered those in the private sector. However, a large majority of those in the public sector were younger and inexperienced, and difficulties arose in providing them sufficient supervision and guidance (Ministry of Health Malaysia, 2016b).

Several strategies were employed to address the situation, including a moratorium on the establishment of new training programmes for doctors, dentists, pharmacists and nurses; rationalising and consolidating existing programmes; and capping the annual intake in each school. Universities were encouraged to offer post-graduate training of doctors in specialist areas instead of focusing solely on basic under-graduate programmes (see Case Study 8.1 and the later sub-section on ‘Issues related to the growing trend of specialisation’). For nurses who had graduated from substandard nursing programmes, special re-training programmes were implemented in both public and private colleges. This facilitated their subsequent employability, particularly in the growing private hospital sector. Pharmacy graduates were allowed to perform their requisite pre-registration training in the private sector.

Expansion of categories of staff.

The shift of basic training to the education sector and the establishment of the MQA served well in providing standards for training, recognition of qualifications and establishing remuneration criteria for a large and growing number of allied health professionals. By 2012, the MoH was employing 31 different categories of allied health professionals who had graduated from accredited diploma or degree programmes in colleges and universities. Both public and private sector hospitals began to establish units and programmes that required the skills of these personnel. Practice modalities within health service delivery changed from a heavy focus on the doctor towards a team approach that reflected the growing competence levels of the allied health and other professional groups. In turn, this team approach was integrated into teaching–learning situations in human resources development.

Continuing education.

Participation in continuing education and access to regularly updated practice guidelines is one of the strengths of the Malaysian health workforce. For those in the public sector, the employing agencies (the MoH and other ministries) organise and fund continuing education activities through the various training institutions, hospitals and the NIH. In the private sector, professional bodies take on this role, often in association with pharmaceutical agencies. The MoH also takes the lead in assembling teams of specialists to develop practice guidelines using systematic reviews and other relevant information produced by the health technology unit.

Governance structure and procedures that had served the earlier established medical, dental, nursing, medical assistant and pharmaceutical professions well were replicated to cover several newer categories (Box 8.7).

Specialist competencies.

Healthcare services delivery required increasingly complex skills from its workforce to address the growing numbers of patients with complex and multiple disease presentations. They had to use new medical technologies that became available every year. This resulted in a trend toward specialisation, where a small section of the workforce gained much higher competencies in selected fields of medical care.

Issues related to the growing trend of specialisation.

The number of such specialised fields is growing steadily. Table 8.9 gives examples of the fields of specialisation and the relevant governance mechanisms established to control quality and safety of practice. This growth presents the continuing challenge of producing sufficient trained personnel for each field and distributing them equitably in the health system. Additionally, as the number of specialities increases and the field of each specialisation narrows, particularly for doctors, there are concerns that this could lead to the management of specific manifestations of diseases and health conditions rather than holistic treatment of the patient. Team approaches mostly focus on multi-disciplinary teams of health professionals and allied health professionals but less on teams of senior clinical specialists.

Doctors and dentists undergo specialist training in university-based training programmes. However, as with basic training programmes, specialist training depends on MoH hospitals to provide the very large component of clinical and practical training. Such training requires supervision from specialists in MoH hospitals. As specialists capable of providing supervision are frequently limited in number, there is insufficient capacity to produce specialists at the rate they are needed (the case study illustrates the dynamics of this situation). Consequently, it is difficult to achieve the desired distribution between the geographic regions. Several strategies have been formulated to improve access in the face of the inequitable distribution.

Table 8.10Examples of specialisation and the relevant governance mechanisms

Sources: World Health Organization, 2014; National Specialist Register, n.d.

This developmental process has also created new tensions. For example, nursing education has progressed from certificate-level training within the MoH to diploma and degree status in universities. However, the majority of nursing positions in the MoH, the major employer of nurses, are for certificate- or diploma-level candidates. The nursing profession continues to struggle to attain professional status commensurate with degree holders. The role of nursing degree holders in the health sector is as yet unclear, illustrated by the fact that speciality training is limited to credentialing existing nurses with experience rather than requiring further training and qualifications as is the case for doctors. Meanwhile, a dilemma arises from the need for personnel who perform the simpler tasks of bedside nursing. These tasks used to be performed by assistant nurses, a category that no longer exists. Interestingly, more ‘developed’ countries are eyeing Malaysia’s expertise in training assistant nurses as a possible solution to nursing needs arising in their own countries. Another issue is whether the health workforce is sufficiently prepared to address the changing epidemiological picture, with high rates of non-communicable disease together with the ability to mobilise communities to empower individuals and families to take responsibility for their health.

8.5.1 Equitable Distribution

Specialist doctors are the most expensive category of healthcare worker and the category for which equitable distribution is the most difficult to achieve. The distribution of selected illustrative key specialist doctors in 2013 was, as expected, highest in the West Coast states of Peninsular Malaysia, but there was a much smaller difference between the Peninsular East Coast states and East Malaysia (Figure 8.4).

Figure 8.4

Distribution of selected specialist doctors in Malaysia, 2013.

Source: Ministry of Health Malaysia, 2016b.

8.5.2 Utilisation: Level of Utilisation and Equitable Utilisation

The Malaysian Health Care Demand Analysis in 2013 noted that the per capita outpatient visits to doctors in Malaysia ‘are comparable with the lower end of the range of levels seen in OECD economies, and about average for countries in the Asia Pacific region with available estimates’. It also found that utilisation had increased from one consultation per capita in the 1930s to >4 consultations in the 2000s. This came from increased utilisation of the public sector starting from the 1960s and 1970s and the rapid increase in utilisation of the private sector after 1980 (Health Policy Research Associates et al., 2013) (Figure 8.4). In terms of equitable utilisation, the study found that ‘the poorest 50% of the population used almost two-thirds of … visits to public facilities, whilst the richest 50% of the population account for two-thirds of visits to private providers’. Similar patterns were observed for the utilisation of inpatient services. Unfortunately, the study did not report on differentials in utilisation in the three geographic regions.

8.5.3 Satisfaction

Human resources play a large role in determining client satisfaction with healthcare services. The community perception module of the 2015 National Health and Morbidity Survey obtained user satisfaction scores on several aspects of services in clinics and hospitals in the public and private sectors. In terms of provider behaviour, more than 70% of users of clinics and hospitals recorded satisfaction levels of ‘good’ or ‘excellent’ in terms of ‘ability to give diagnosis and treatment’, ‘give clear explanations’ and ‘courtesy and helpfulness’. There was little difference between the satisfaction levels reported by users of public and private facilities (Figures 8.5 and 8.6). However, among the other aspects of care, the main source of dissatisfaction regarding public sector clinics and hospitals was waiting time, whereas that for the private sector was treatment charges (Figures 8.5 and 8.6).

Figure 8.5

Reported satisfaction with public and private clinics, 2015.

Source: Institute for Health Systems Research, n.d.

Figure 8.6

Reported satisfaction with public and private hospitals, 2015.

Source: Institute for Health Systems Research, n.d.

8.5.4 Quality of Care

While many factors contribute to quality of care, provider competence and behaviour is a crucial factor therein. During the 1980s, Malaysia was a leader among the developing nations in developing systematic monitoring and improving quality of care in the health sector. The aim has been to encourage the adoption of a mindset for quality and care that ensures good monitoring and improvement practices among healthcare providers. Although there is a wealth of data from the public sector, data from the private sector are limited, thereby limiting the overall estimate of quality of care.

A 2016 study by an international group from the Harvard T. H. Chan School of Public Health and the MoH (Ministry of Health Malaysia & Harvard T. H. Chan School of Public Health, 2016) used data from the National Medical Care Surveys (NMCS 2012 and 2014) (Clinical Research Centre, 2014) to replicate 66 indicators to analyse the quality of primary care. They found that ‘patients received around 57% of recommended care’ and that ‘these estimates are close to the aggregated quality of care estimates found in the United States and Australia, which range from 55 to 57% although the estimates are not strictly comparable due to differences in the set of indicators used and patient case mix’.

Systematic data for hospital care were limited (Ministry of Health Malaysia & Harvard T. H. Chan School of Public Health, 2016). However, based on mortality rates for common acute conditions, they found that

It could be concluded that the quality of clinical care provided by the Malaysian health workforce is generally within acceptable standards.

8.7.1 What Went Well?

• The composition of the workforce was crucial in the development of an affordable healthcare system. Key features were:

  1. ◦ The availability and competence of staff to deliver key tasks at the sites where they were required.

  2. ◦ Nurses, midwives and medical assistants formed the backbone in the early years.

  3. ◦ ‘Task shifting’, although not acknowledged formally, was practised in accordance with specific service needs.

  4. ◦ Educational curricula for all categories were closely aligned to explicitly defined competencies required in healthcare services.

• The health workforce was shaped flexibly to respond to demands from the health services:

  1. ◦ through recognition of opportunities and threats in the larger ecosystem and the appropriate use of:

  2. ◦ governance (e.g. registration, annual licensing, defined standards for eligibility to practise, wage and benefits packages), and

  3. ◦ financing mechanisms (such as publicly funded training).

• Foreign inputs were used strategically to develop and support local resources.

8.7.2 What Did Not Go So Well?

• The structural divide between the public and private sectors contributed to:

  1. ◦ brain drain from the public sector to the private sector, and

  2. ◦ a consequent difficulty in achieving geographic equity in distribution of staff.

• There were gaps in co-ordination between production (education) and utilisation (health) due to weak institutional mechanisms.

8.7.3 Trends and Challenges

• Rising expectations of the workforce and the public create the risk of mismatch between workforce competencies and the community’s healthcare requirements.

• Rapid development of technology will require new competencies and render some competencies redundant.

9.5.1 What Went Well and Not So Well?

• For the first 45 years, with a relatively young population, it was possible to achieve relatively good outcomes with relatively low health care expenditure.

• However, the system needs to adapt to new challenges to continue reaping such benefits (relatively affordable health care).

• With a hybrid public–private financing and delivery system:

  1. ◦ The public sector, which is welfare-oriented, uses pooled tax funds to provide:

     • access and financial protection to the poor, and

     • protection from catastrophic health expenditure for households – a safety net for all sectors of the population.

  2. ◦ The private sector initially complemented the public sector by catering for those who could afford it, but it now has an increasing share of OOPP expenditure due to:

     • low private health insurance uptake, and

     • fee-for-service provider payment mechanisms.

  3. ◦ This threatens social efficiency in the provision of health care.

9.5.2 Trends and Challenges

• Health expenditure is likely to rise (due to an ageing population, epidemiology and technology).

  1. ◦ With the current system, this is likely to result in rising OOPPs.

  2. ◦ If pooled funding is used to address OOPPs in the private sector, there is likely to be increased utilisation of the private sector with higher health expenditure unless prices are controlled effectively.

10.3.1 People and Their Health

During the immediate post-independence years, the MoH used a range of information that was already available to develop health priorities and to monitor the implementation of health interventions. For example, empowered by the relevant legislation, the DoS conducted population censuses through household surveys that provided basic information on the number, location and characteristics of the people in the country. The DoS also collected data on births and deaths; police throughout the country, together with hospitals, were responsible for registering and reporting births and deaths. Thus the 1957 census showed that three-quarters of Malaysian people lived in rural areas (Department of Statistics, 1960), and the DoS provided annual population estimates between censuses using data from the existing system of registering births and deaths. Additionally, registering births and deaths provided annual information on fertility and infant mortality. For example, fertility was about three times the replacement level, and infant mortality was high and the associated life expectancy was relatively low (Reference Fernandez, Hawley and PredazaFernandez et al., 1975).

The MoH also collected and compiled data from hospitals on causes of admission and of death. Deaths registered by the police were not usually medically certified. However, the limited available information indicated that most mortality was related to infectious diseases such as malaria and tuberculosis (Reference RoemerRoemer, 1976). Surveys of education status showed that about three-quarters of the adult population (≥15 years of age) were illiterate (Ministry of Education Malaysia, 1967). Similarly, household budget surveys showed that most people in rural areas lived below the poverty line (Reference RoslanRoslan, 2001). Concerns about toddler mortality rates (1–4 years of age), known to be associated with malnutrition, led to a joint applied nutrition programme by the MoH and other ministries (education, information and agriculture). An evaluation study performed in 1979 showed enhanced child nutrition practices and weight gains (Ministry of Health Malaysia, 1982; Chapter 4).

Legislation required the reporting of dangerous and infectious diseases to the MoH, and such information provided the basis for the disease control measures described in Chapter 6. Once the various disease control programmes had been developed, each established its own information system, including the monitoring of disease and deaths and programme activities (Chapter 6).

Household surveys, such as those for 1957–1958 and 1973–1974 (Reference Young, Bussink and HasanYoung et al., 1980), also yielded an assessment of household use of health services and their distribution among different income groups.

10.3.2 Health Workforce

Legislation required the registration of nurses, midwives, doctors, dentists and pharmacists in both the public and private sectors (Chapter 8; Federation of Malaya, 1957), providing annual estimates of the distribution of health professionals. For example, the number of nurses and doctors per head of population was relatively low. Also, while health-related information showed that the major determinants of health were related to the poor living conditions in rural areas, information from the registration of health professionals indicated that most nurses worked in public hospitals, while more than half of the doctors were in the private sector (Department of Statistics, 1964; Chapter 3; Chapter 8). Such information guided the formulation of policies related to human resources (Chapter 8). Annual registration data enabled monitoring of the progress made to increase low numbers in relation to the growing population. In addition, an annual census of doctors and dentists in the private sector carried out since the 1970s (e.g. Department of Statistics, 1975) enabled assessment of the public–private distribution of the health workforce and guided the mobilisation of scarce health professionals, especially for rural areas.

10.3.3 Health Facilities and Services

The MoH routinely collected information on public sector health facilities and their basic activities, such as number of admissions and ambulatory patient encounters. This information indicated that most hospitals and clinics were located in urban centres and that most hospitals in the private sector were relatively small and most were concerned with maternity services. Such information guided planning for expanding the rural health service and strengthening the public hospital network (Chapters 4 and 5). For example, there were an average of two public sector beds per 1,000 people (excluding special institutions) (Federation of Malaya, 1959). This would be considered a relatively high ratio for a young population, although some beds were reserved for patients with tuberculosis and other infectious diseases. At that time, data collected from hospitals were rudimentary, such as number of admissions and patient encounters. It did not permit the evaluation of functions. About 20 years after independence, a purpose-designed survey of hospitals showed low occupancy rates in small hospitals but very high occupancy in larger hospitals in the greater urban centres (Chapter 5; Institute for Public Health, 1983), triggering several initiatives for improving services in smaller hospitals.

In rural areas in 1960, there was only one main health centre per 600,000 people, one sub-centre per 320,000 people and one midwife clinic per 120,000 people (Reference IsmailIsmail, 1971). Data were also collected on the number of visits to health centres for maternity and child health and on public hospital outpatient services. Such information mainly supported decisions related to staff deployment and the supply of medical products, including vaccines, to public sector facilities. After 17 years of rigorous expansion of the rural health service, the MoH conducted a household survey: a high proportion of villages were ‘underserved’, and this finding triggered the re-vamping of the rural health service (Chapter 4) to rapidly increase access to front-line staff through revised staffing patterns and mobile clinic services. In 1968, an environmental sanitation survey in selected rural areas indicated that only 4% of the population was served with piped water, and the remainder obtained water from either unprotected wells or untreated surface water (Ministry of Health Malaysia, 1982), and this triggered a re-vamped approach to rural sanitation (Chapter 7). Annual data compiled and analysed by the MoH enabled the government to monitor progress in comparison to the targets, as discussed in Chapters 4–8.

10.3.4 Health Financing

During this phase of development, information available on health financing was mostly from the government’s financing of health services and their administration in the public sector. At about the time of independence, public sector expenditure on health amounted to about 1.4% of the gross domestic product (GDP) (Federation of Malaya, 1957; 1959; 1961; Department of Statistics, 1999; Chapter 9). Since the 1970s, the annual census of private doctors, dentists, maternity homes and hospitals also reported revenues of, and expenditures incurred in, related private practice (Department of Statistics, 1975). Central government agencies used this annual census mostly to monitor growth in private health sector employment and economic activity. Household expenditure surveys such as that for 1957–1958 yielded an estimate of households’ health-related expenditures (Reference RoemerRoemer, 1976; Chapter 9).

10.3.5 Information Supported the Assessment of Progress

10.4.1 People and Their Health

The population censuses, vital statistics, disease registers and surveys of internal migration continued to provide information on population growth and characteristics as well as disease occurrence. The MoH used this information to assess the population covered by services such as immunisation and to assess the progress made in reducing mortality and disease incidence. Household living condition surveys indicated that poverty was substantially reduced during the 1980s and 1990s (Chapter 3). Nevertheless, continuing concerns regarding possible lags in reaching the poor and their health led to health assessments of the very poor to ascertain the appropriate support to be provided (Ministry of Health Malaysia, 1992).

However, changing disease patterns drove the need for better information. For example, non-communicable diseases were not notifiable, and the only available data were those collected from admissions and deaths in public sector hospitals. Similarly, dental health data were limited to the provision of dental service. The need for community-wide information led the MoH to initiate large-scale population-based surveys that were to become a regular feature in the future. An example is the first National Health and Morbidity Survey in 1986–1987, a comprehensive household survey on access and use of health services, health-related behaviour and morbidity from non-communicable diseases such as hypertension and diabetes mellitus (Institute for Public Health, 1988). The survey was repeated in 1996 (Institute for Public Health, 1999) and more frequently in subsequent decades. Other examples include oral health surveys of six-year-old school children (Dental Division, 1972a) and of adults (Dental Division, 1972b), which provided data on oral health and the need for services. Such surveys subsequently formed a regular surveillance system on oral health.

Another aspect of health information was health systems research (HSR). The driver motivating the development of HSR was the thrust to improve management within the MoH to respond better to the national policy of improved effectiveness and efficiency (Chapters 4 and 5). Beginning with a small unit within the Institute for Public Health, which at the time was mainly a training institution, HSR proved its value to the MoH and was soon developed into a major programme with international credentials, subsequently meriting its own institution.

10.4.2 Health Workforce

During this phase of development, new legislation commenced requiring the registration of additional categories of personnel – assistant medical officers, opticians and optometrists – thereby increasing the human resources information database. However, as the numbers of health professionals increased, the system’s capacity for updating the database regularly was limited (World Health Organization, 2014). Therefore, the registers maintained by the respective boards became less valuable as a source of information for planning and policies regarding the health workforce. Mainly, the boards used the information to regulate professionals (Chapter 12). Meanwhile, information required for health workforce planning was deficient, contributing to gaps in planning. For example, the progressive transfer of health personnel education from the MoH to the MoE resulted in information lags between the two ministries, creating a barrier to forward planning by the MoH, the main user of health personnel. Furthermore, the MoE did not obtain data from all sources that produced health personnel, namely private sector institutions and foreign institutions. The time lag and incomplete data later resulted in serious problems of employment, as discussed in Chapter 8 and Case Study 8.1.

Box 10.1 illustrates the initial development of HSR in Malaysia.

10.4.3 Health Facilities and Services

Information from the sources described earlier in this chapter continued to provide data that showed, for example, that although the number of total hospital beds increased, the beds-to-population ratio in the public sector declined, partly compensated by the substantial rise in private sector beds (Chapter 5). Data showing the rising prevalence of small private hospitals was a factor in triggering the formulation of new legislation to regulate private hospitals. Similarly, data showing the increased utilisation of health centres in the public sector for ambulatory care contributed to the transfer of outpatient services from hospitals to health centres (Chapter 4). The introduction of the quality assurance programme (QAP) in several MoH programmes contributed to better data quality, such as in the accuracy in International Classification of Diseases (ICD) coding of deaths or discharges from hospitals. It also resulted in better use of information, as the QAP required evidence of remedial measures by institutions, whose performance on selected indicators suggested the need for immediate improvement (Chapter 5).

10.4.4 Health Financing

As described earlier, information on health expenditure was limited to that in the public sector, and there was uncollated and limited information on the private sector. Rising concerns about the sustainability of the healthcare financing system prompted the need for more comprehensive information on health expenditure. The first major assessment of healthcare financing was carried out in the 1980s by external consultants (Westinghouse Health Systems, 1985) in conjunction with the study of the possible introduction of social health insurance in Malaysia (Chapters 3 and 9). The study provided sufficient information for a policy decision not to implement social health insurance. A household health expenditure survey provided information on out-of-pocket expenditure on health for 1996 (University Malaya, 1999). This led to awareness of the need to gain better understanding of the financial implications of the structural changes taking place to households and the financing of public and private health services. The MoH has undertaken recent estimates on health financing of both the public and private sectors for the late 1990s and consequent years (Malaysian National Health Accounts Unit, 2017). These studies indicate that health financing as a proportion of the GDP rose from 1983 to 2000, with an increasing proportion from the private sector (Chapter 9). This information shows that the government policy of placing greater emphasis on the provision of private health services has a price, and there is a need to provide public sector services as part of the social safety net.

10.4.5 Information Technology Development

Struggling with the increasing amount and varied quality of data generated by the different programmes, the MoH took a significant step towards improving the accuracy and comprehensiveness of health information. It established a central information documentation unit responsible for routinely collating information on all programme activities; checking comprehensiveness and accuracy; and analysing and publishing information on health status, human resources and health service delivery, using DoS information as the denominator. These publications became the source of official information, replacing the several different reports published by individual programmes (i.e. Information and Documentation System) (Ministry of Health Malaysia, 2001; Reference SelvarajuSelvaraju, 2006). The rising availability of computerisation supported the implementation and effectiveness of this initiative to centralise and standardise data generated by the MoH. Progress was incremental, dictated by the cost of new technology and the capacity for training staff at district and state levels to acquire computer literacy.

Another important development was the proposal to establish a telehealth programme, beginning with a Telehealth Pilot Project (Ministry of Health Malaysia, 1997; Suleiman, 2001) to increase IT use to promote the integration of the collection of health information from a variety of sources. Three major modes were envisaged:

• Lifetime health plans

• Teleconsultation

• Information and education

The first was to provide a lifelong personal health record linked to an electronic medical record. The second was to consist of a multimedia network for face-to-face consultation of individuals and health professionals or among healthcare providers to enhance clinical support. The third was to establish knowledge databases and interactive training programmes and make health information available to the public and to health professionals. By 2000, several projects had been initiated, such as the Medical Care Information System for collecting patient information in MoH hospitals, the Communicable Disease Control Information System for collecting information for the surveillance and management of communicable diseases, and the Maternal and Child Health System for collecting and analysing information from MoH services (Ministry of Health Malaysia, 2002).

As one of the pioneering efforts in telehealth globally, the Telehealth Pilot Project encountered numerous implementation challenges and was stopped for re-evaluation in 2000. Subsequently, the scope and financing of telehealth implementation was scaled back. The Information Management Division remains responsible for telehealth as a whole; however, in practice, the various projects emerging from the original initiative have been taken over by the relevant MoH divisions, which determine the pace, scope and objectives in their implementation.

As discussed in detail in Case Study 10.1, systems interoperability was a key obstacle to implementing and scaling up the telehealth project. This continues to be a challenge, with no overall interoperability standard defined yet. At present, interoperability issues are being addressed on a case-by-case basis based on the needs of a particular application or system. The Health Informatics Centre (HIC) has been working to develop and promote the adoption of standards and terminology for the healthcare industry in Malaysia and to audit documentation to ensure data quality. While adherence to standards set by the HIC has been good, data quality remains a work in progress.

10.4.6 Assessment of Progress in Health Outcomes

10.4.6.3 Equity

The information available for both service coverage and health outcomes of the population in different states indicated that access and use of services continued to improve in those states with the greatest need. Differences continued to prevail, but they became smaller (Chapters 3–7). Household surveys also showed that exempting the poor from fees for public health services lessened the financial burden for the poorer people (Chapter 9).

Box 10.2System observations: closing the feedback loop to improve data collection

Health information systems are crucial to creating learning feedback loops that enable health system strengthening. However, the actors who collect the data may not recognise its value, resulting in poor data quality. In developing this volume, we came across several accounts in which data collection and entry were low priorities for both hospital administrators and ground-level medical personnel, who were motivated by tasks that had direct impacts on patient outcomes. When data were used to evaluate and improve hospital performance, however, hospital administrators responded by making proper data entry a high priority and communicated that to the hospital workforce (Figure 10.1).

Figure 10.1

Reinforcing loop showing how compliance with data collection improves the quality of data, enabling positive impacts on health outcomes. When health system personnel are able to observe these impacts, the intrinsic motivation improves the level of compliance in data collection. Conversely, when this connection is not made, data collection can be perceived as a box-ticking exercise, compromising the quality of data collected.

Box 10.3System observations: use of health information for single- and double-loop learning

Health information can be used to improve the implementation of health strategies towards existing goals (single-loop learning). Such learning seeks to improve the performance of the health system within existing paradigms and is important for health system strengthening. The role of household health surveys in the establishment of ‘Healthy Lifestyle’ programmes provides a different example in which health information catalysed a paradigm shift. Here, health information was used to determine whether the existing goals of the health system were appropriate and adequate (double-loop learning)

10.5.1 People and Their Health

The decennial census of population and inter-census estimates continued, and they showed that the majority of people lived in urban areas, with the possible exception of Kelantan (Department of Statistics, 2011). The proportion of registered deaths that were medically certified increased from 39% in 2000 to 51% in 2014. However, the quality of data on the cause of death remained inadequate for policy and planning. For example, in 2013, the cause of death classification for 30% of deaths was unacceptable. Among the medically certified deaths, 12.5% were assigned to ‘symptoms, signs and ill-defined conditions’; among the non-medically certified deaths, 60% were assigned to ‘old age’ (Reference Omar, Ganapathy, Annuar, Khoo, Jeenanathan, Awaduddin, Yn and RooOmar et al., 2019). The continued use of household health surveys provided more abundant information on health-related behaviour and the characteristics of the users of services, while some surveys focused on specific health aspects such as adult nutrition (Institute for Public Health, 2014), non-communicable diseases (Institute for Public Health, 2015), maternal and child health (Institute for Public Health, 2016), and adolescent (Institute for Public Health 2018) and elderly health (Institute for Public Health, 2019). This information supported the refinement of health strategies and programmes in specific areas discussed in Chapters 4–6.

10.5.2 Health Workforce

Institutional re-organisation transferred responsibility for the pre-service education of most categories of health personnel to the MoE (Chapter 8). As a result, within the MoH, all aspects of human resource management became the purview of the civil service arm of the MoH. As discussed in Chapter 12, the consequence was policies and management focused on MoH staff but not on the health workforce of the country. Information aspects of the health workforce that were essential for policy and planning were dispersed between various ministries and between departments within the MoH. Examples of such information include entry and output from training programmes, entry and exit from the workforce, geographic- and discipline-specific deployment and ratios between various categories. No single agency is responsible for collating, aggregating and analysing nationwide information. Spurred by a WHO effort to construct the health workforce profiles of member countries, the MoH initiated a major study (World Health Organization, 2014) to compile nationwide information that provided sufficient information for identifying key gaps in policies and impending problems in the workforce, some of which are illustrated in Chapter 8. Efforts are ongoing to institutionalise the routine collation and analysis of such information and to strengthen policy and planning by using it to make estimated projections for workforce requirements and supplies for the future.

10.5.3 Health Facilities and Services

The MoH maintains an inventory of health facilities in the public and private sector that enables it to monitor trends in the number of and the capacity of public and private facilities per head of population. This information supports policies and planning, for example, for expanding hospitals or clinic networks (Chapters 3–5). However, information on services availability in health facilities is limited to the public sector. The MoH conducted facility surveys through its Clinical Research Unit (Clinical Research Centre, 2014) in the private and public sector for a few years, creating a comprehensive picture that enabled the analysis of gaps and utilisation patterns, particularly of specialised services in hospitals and clinics. However, in subsequent years, although the private sector provided much of the information required by new legislation, the MoH did not institutionalise mechanisms for collating and analysing such information. The quality of services provided by health facilities in the public and private sectors became available from the quality accreditation programme (Malaysian Society for Quality in Health, 2018; Chapter 12).

Growing management competence in the MoH and international emphasis on evidence-based decision-making in healthcare produced a thirst for a wide variety of information. For example, several clinical specialist groups established disease registers for their specialities to provide evidence of the effectiveness of clinical interventions. In response to requests from MoH programmes, the National Institutes of Health (NIH) conducted an increasing number of studies to evaluate interventions or analyse problems. Examples include evaluation of the cluster hospital concept (Institute of Health Management, 2016), analysis of healthcare demand (Health Policy Research Associates et al., 2013) and attitudes towards tobacco smoking (Reference Tee, Hairi and HairiTee et al., 2012). Similarly, local universities produced increasing numbers of studies related to the Malaysian health system and its programmes. There is a growing challenge in keeping track of such outputs and providing convenient access to researchers and managers.

10.5.4 Health Financing

The NHA programme started by the MoH in 2001 (Ministry of Health Malaysia, 2018) made a major difference to the information available and the periodic assessment of health financing in both the public and the private sector and their relative evolution since 1997 (e.g. Malaysian National Health Accounts Unit, 2017). NHA data are quoted widely in reports and discussions, demonstrating that it has raised wide awareness of the issues related to health financing. Analysis of health expenditure showed substantial growth in health expenditure as a proportion of the GDP, from 3.3% in 2000 to 4.6% in 2015, and the relative importance of private health expenditure, which amounted to almost half (48.5%) of the total (Chapter 9).

10.5.5 Medical Products

In addition to information related to the regulation of pharmaceutical products in Malaysia and the use of pharmaceutical products and medical devices, the MoH has conducted surveys since 2004 on the use and prices of medicines (e.g. Ministry of Health Malaysia, 2006) and also later on medical devices (e.g. Ministry of Health Malaysia, 2009). Price negotiations for the procurement of medicines for the MoH use some of this information (Chapter 11).

10.5.6 Information Technology Development

The initial proposals for the greater use of IT in MoH information systems (Ministry of Health Malaysia, 1997) were further developed in proposals for a Malaysian Health Data Warehouse (MyHDW) (Ministry of Health Malaysia, 2013). This continues to be under development, with all the constraints usually encountered with IT systems development of a very comprehensive nature. By 2016, progress had been achieved in the collection, storage and processing of information on each hospital inpatient and in the production of related reports (Ministry of Health Malaysia, 2018).

The growing interest in producing and using information from research led the MoH to take the lead in establishing a national process to identify research priorities that guide public sector funding for research in Malaysian academic institutions as well as the NIH under the MoH (Reference Suleiman and MericanSuleiman & Merican, 2000). The rapid escalation in the volume of information from different systems created the need to create and maintain websites providing convenient access. It also required discussion forums to disseminate information. The NIH took the lead in collaborating with local and international academic institutions to provide regular forums for disseminating information and encouraging discussion. While this is evidence of progress, many institutions continue to struggle with issues of systematic cataloguing of research and providing access to research products. Another aspect of access to information is that while the MoH has a wealth of data from various sources, researchers outside the MoH system experience difficulty accessing it. Processes for making the data more accessible without compromising integrity are in the developmental stages.

10.5.7 Health Outcomes

10.7.1 What Went Well?

• Spurred by demands from increasingly competent managers and clinicians, the health information system, in incremental steps:

  1. ◦ used information from health and non-health sources (census, income),

  2. ◦ steadily improved the timeliness and quality of data, and

  3. ◦ embraced initiatives that added analytic and evaluative information (health systems research, quality improvement, disease registries, technology assessment, NHA).

• The utilisation of data and information spurred improvement in data quality.

• Continuing efforts are needed to harmonise and standardise data generated by different information sub-systems that evolve with growing healthcare systems.

10.7.2 What Did Not Go So Well?

• Inadequate infrastructure, managerial capacity and demands on financial and human resources hampered ambitious digitalisation plans.

• In the interests of safeguarding confidentiality, academicians and researchers outside the MoH have inadequate access to health information.

• There is inadequate collated, analysed information on private sector healthcare and on occupational and environmental health.

10.7.3 Trends and Future Challenges

Increasing digitalisation is expected to bring great benefits if the system is able to address the difficult challenges of platform interoperability and concerns about confidentiality in relation to legal requirements, personal privacy and commercial interests.

11.3.1 The Driving Forces

Earlier chapters discussed how the first couple of decades following independence focused on increasing access to healthcare for the rural population through integrated development of the health sector within the broader socio-economic development of the country. A key component of the healthcare system was the supply of medicines free of charge to patients who attended public sector facilities. The budget of the Ministry of Health (MoH) bore the cost of these drugs. The number of health facilities, particularly in rural areas, increased rapidly (Chapters 3 and 4), and national programmes for controlling communicable disease spread throughout the country (see Chapter 6). All of these required a reliable supply of medicines and vaccines. Therefore, the initial focus was on the import, storage, distribution and dispensing of medicines (Pharmaceutical Services Programme, 2013).

11.3.2 Import, Production and Purchase of Medicines

For the first 15 years, most medicines were imported, and the Crown Agents had a near monopoly on the import of medicines and vaccines for public sector facilities (Federation of Malaya, 1962; British Resident Selangor, 1903). Subsequently, local agents took over this role. However, parallel import of a patented product from an alternative source was allowed, and this provided a less costly alternative source for a patented product. A few multinational pharmaceutical companies also imported and distributed medicines to the few private pharmacies and wholesalers, which in turn supplied them to private medical practitioners and public sector facilities.

The public pharmaceutical sector initially focused on developing logistics to ensure supply to the rapidly expanding network of healthcare facilities. The MoH constructed a large central Government Medical Store (GMS) that became responsible for acquiring supplies from agents and in turn supplying medicines to all MoH facilities through a transport network. Hospitals and state stores submitted invoices and obtained most of their medicines from the GMS (Box 11.2).

Meanwhile, the GMS progressively developed the capacity for manufacturing medicines, and by 1970, it manufactured more than 150 types of pharmaceutical products, including tablets, large-volume intravenous fluids, injections in ampoules (including morphine and pethidine) and galenicals.¹ A few large hospitals supplemented the GMS production capacity by manufacturing intravenous solutions and galenicals for their own use. There were only a few private pharmaceuticals manufacturers, such as Glaxo and Sterling Drugs, which were foreign companies with manufacturing plants in Malaysia (B. Yeap, recollections of early pharmacy services in Malaysia, personal communication to Thomas Paraidathathu, 2016). Moreover, the Institute of Medical Research (IMR) also produced a range of vaccines for a time (Reference Ramanathan, Cheah and DonderoRamanathan et al., 1976). The first Malaysian private pharmaceutical manufacturing company was the Malayan Pharmaceutical Factory (MPF) in Petaling Jaya. By the 1970s, more pharmaceutical manufacturers were set up in Melaka, Sungai Petani, Port Klang and Bangi (Malaysia Competition Commission, 2017). Thus, while hospitals and the GMS catered to the government hospitals, the private pharmaceutical manufacturers catered mainly to the private hospitals and clinics and sometimes, through tenders, also supplied the MoH.

11.3.3 Quality and Safety

During this phase of development, the system relied on the legislation that was already in place. However, from time to time, the MoH also issued circulars to ban the import and use of certain drugs or chemicals, such as phenformin, or re-classified them in the Poisons List to restrict their use. There was hardly any enforcement capacity; therefore, the MoH gradually built up the capacity for oversight. Box 11.3 shows the key landmarks in this process.

Prior to 1985, Malaysia did not require local registration of a medicine. Unless the MoH banned a product, importers or manufacturers could sell it in the country. Additionally, some manufacturers in the country used premises that were unsuitable for manufacturing and preparing medicines (e.g. garages and shophouses). They had a very poor understanding of the concept of good manufacturing practice (GMP). The quality of medicines and their compliance with pharmacopoeia standards were unknown (S. Selvaraja, experiences as a pharmacy regulator, personal communication to Thomas Paraidathathu, 2018). Furthermore, there were no inspections of manufacturing premises or licensing requirements from the MoH.

Also, as local registration of a product was not required, the Malaysian government suspected that some multinational pharmaceutical companies were ‘dumping’ their products in the country. For example, an analgesic product containing the drug dipyrone, which the US FDA² had banned, was available in Malaysia.

However, this period also witnessed the first baby steps for improving the quality of medicines dispensed at public sector facilities. Patients used to bring their own containers to public sector hospitals and clinics for oral solutions, lotions and eye drops.³ Such containers had inconsistent levels of cleanliness and sizes. Therefore, in 1979, the MoH decided to supply medicines in plastic containers, enabling standardised and hygienic packing. Moreover, pre-packing speeded up the dispensing process. In the private sector, quality and safety depended on the professional integrity of the medical profession and private pharmacies and their adherence to professional and legal requirements to prevent wrongful use of prescription medication. In 1983, inspired by the WHO initiative on essential drug lists, the MoH produced its own Blue Book, listing essential drugs for MoH facilities. This formed the basis for standardising the availability of medicines at each level of the facility in MoH services.

11.3.4 Prescription, Dispensing and Human Resources

During the first decade after independence, the very few Malaysian pharmacists trained mainly in Singapore, Australia or the United Kingdom. At the start of the second decade after independence, a local university established a training programme, but its output was limited. As population growth was relatively rapid, the ratio of pharmacists to population remained low. Dispensing medication was the responsibility of medical assistants⁴ in the public sector facilities and of clinic assistants under the supervision of doctors in private sector clinics. To address the need for personnel, particularly for hospital pharmacies, an allied health profession of dispensers was introduced, with one year’s training in a newly established Dispensers Training School followed by on-the-job training at hospitals. Gradually, the dispensers replaced medical assistants for dispensing in the public sector facilities (Pharmacy and Supplies Programme, 1996; G. Singh, experiences as a dispenser in the early years, personal communication to Thomas Paraidathathu, 2012).

11.3.5 Outcomes

Although there is no direct information on the availability of and access to medicines and vaccines, the success in reducing vaccine-preventable deaths (see Chapter 4) and malaria (see Chapter 6) and the rapid increase in the utilisation of hospitals and clinics (see Chapters 4 and 5) suggest adequate access to and use of basic medicines and vaccines. As discussed in Chapters 4–6, the availability and use of effective vaccines and medicines contributed to the changing profile of hospital bed utilisation.

11.4.1 The Driving Forces

During the next two decades after independence, Malaysia experienced stable politics, continued economic growth with a few downturns, rapid urbanisation due to rural-to-urban migration, and a demographic and epidemiologic transition (see Chapter 3). The incidence of communicable diseases declined while the prevalence of non-communicable diseases increased. (see Chapters 3–6). Meanwhile, the advent of newer pharmaceutical products and international research on effectiveness and risks changed medical care practices. One example is the management of eclampsia of pregnancy, where the use of magnesium sulfate enabled nurses in more remote settings to initiate effective management without awaiting the availability of a doctor.

11.4.2 Import, Production and Sale: Quality and Safety

11.4.3 Purchase: Effectiveness and Cost of Medicines

In the face of the growing choice of available medicines, the need for rational choice became a priority, particularly considering the national policy of providing highly subsidised medicines almost free to clients in public sector healthcare facilities. In 1983, the MoH established a system for selecting medicine eligible for purchase by the MoH through the Ministry of Health Medicines Formulary (MOHMF). An MoH review panel comprising representatives from different clinical disciplines uses criteria such as efficacy, safety, budget impact and ethical considerations for selecting items from the MOHMF. Other methods of selection include multi-criteria decision analysis (MCDA). The review panel aims to ensure that selection is transparent, predictable and considers the value to the community of patients and the cost of a drug. For example, if the cost of a drug were so prohibitive that only a fraction of the patients who need it would receive it, it would not qualify for inclusion in the MOHMF. The MOHMF is updated regularly, and in 2017, there were 1,676 drugs in the list. Other healthcare providers in the public sector, such as teaching hospitals and the Ministry of Defence, have their own formularies.

11.4.4 Prescription, Dispensing and Human Resources

For the first 25 years of independence, there was only one pharmacy school in Malaysia, with a small output that was augmented by a trickle of pharmacists trained abroad. In 1990, there were only 1,239 registered pharmacists (less than 1 per 10,000 population) (Ministry of Health Malaysia, 2000). The rapid expansion of the pharmaceutical sector was accompanied by the concentration of the available pharmacists in the private sector. In 1996, 77% of pharmacists were in the private sector (Ministry of Health Malaysia, 2000).

Due to the limited availability of pharmacists, their traditional role in the MoH during the 1950s to 1980s was in functions related to improving medicine quality and safety, enforcing standards for medicines and in the procurement and supply of medicines for patients. In the public sector, dispensing remained in the hands of assistant pharmacists, and in the private sector, largely in the hands of clinic assistants and their supervisory doctors. With the gradually increasing availability of human resources, pharmacists in MoH hospitals began to advise on individualised drug therapy, re-constituting cytotoxic drugs, providing medication counselling and developed drug information systems in hospitals (Ministry of Health Malaysia, 2002). By 1995, three other pharmacy programmes had begun in Malaysia, thereby boosting production output. The first graduates from these programmes began coming into the market by the end of the 1990s.

11.5.1 Import, Production and Sale: A Stable Regimen for Quality and Safety

The National Pharmaceutical Regulatory Agency (NPRA)⁸ succeeded in constructing a good regulatory framework for pharmaceuticals, and it gained international recognition. Co-ordination with customs authorities was strengthened to monitor consignments of products such as saccharin, beta-agonists, precursor and essential chemicals liable to be misused, for example in illegal traffic in narcotic drugs (Ministry of Health Malaysia, 2002). Additionally, the scope of monitoring extended to traditional products adulterated with poisons such as fenfluramine. In 2002, the NPRA became a member of the Pharmaceutical Inspection Co-operation Scheme (PIC/S), an international non-binding, informal co-operative arrangement between regulatory authorities in the field of GMP of medicinal products. This indicated that the NPRA adhered to internationally acceptable GMP inspection standards. Indirectly, it also validated the standard of the local pharmaceutical industry. The NPRA is also an active member of the ASEAN (Association of Southeast Asian Nations) harmonisation initiatives for the regulatory control of pharmaceuticals. In addition, Malaysia was accepted in 2013 into the Organisation of Economic Co-operation and Development (OECD) system for Mutual Acceptance of Data (MAD) in the assessment of pharmaceuticals. New medicines that are needed in Malaysia but that require more evidence of safety and efficacy are sometimes given conditional registration. Recently, a vaccine for dengue was given a two-year conditional registration. Phase IV clinical trials are still to be conducted, and therefore it has not been given full marketing authorisation.

After an initial slow start during the 1990s, the reporting of ADR to MADRAC improved, accompanied by appropriate regulatory action by the DCA. Figure 11.1 shows the rise in the number of received reports from 2010 (7,079) to 2017 (15,936). The MoH conducted post-marketing surveillance of pharmaceutical products to ensure that registered products continued to adhere to stipulated standards of quality and conditions of use.

Figure 11.1

Number of received reports of ADR.

Sources: Ministry of Health Malaysia, 2010; 2011; 2012a; 2013; 2014; 2015; 2016; 2017.

Counterfeit medicines amounted to less than 5% of all marketed pharmaceutical products. A significant contributor to this healthy scenario is the access to good-quality medicines at low or no cost at government healthcare facilities. The instances where counterfeit medicines were discovered involved medicines with high consumer demand such as Panadol and Viagra. Since 2005, a product-specific hologram was introduced as an additional safety feature for all registered drugs.

11.5.2 Supply Logistics, Prescription, Dispensing: Availability of Medicines

In the MoH system, logistics improved with the increased use of information technology that facilitated modernised inventory management and enhanced storage facilities. The volume of prescriptions in MoH facilities increased rapidly. For example, there was a 12% increase in one year during 2016–2017 (Ministry of Health Malaysia, 2017). Approximately 30–40% of these are repeat prescriptions for patients with chronic illnesses such as diabetes and hypertension who had prescriptions for 3–6 months’ duration. However, dispensing was monthly to monitor for any side/adverse effects, efficiently manage resources, avoid extensive stock holding and reduce medicine wastage resulting from improper storage or expiration. This dispensing practice caused inconvenience and travel costs to patients, congestion, and longer waiting times at pharmacy counters, particularly in the larger healthcare facilities. Several initiatives addressed this challenge. A digitalised Integrated Drug Dispensing System (Sistem Pendispensan Ubat Bersepadu, or SPUB) has enabled patients to obtain their prescriptions at any MoH facility and to do so through an appointment system that enables prior preparation of the prescription, thus drastically reducing waiting times. Other innovations have increased access and convenience. The drive-through pharmacy is a concept borrowed from the fast food and banking industries. The Medicines by Post scheme sends medicines to the patient’s home by a courier company for a fee of RM 6. The Locker4u scheme provides designated lockers, secured by a key/personal identification number (PIN), where patients can collect their medicines from hospitals at their own convenience. Patients who use these initiatives are very satisfied (98% satisfaction) with these services (Pharmaceutical Services Programme, MoH Malaysia, 2016).

As the availability of pharmacists increased, the scope of their service expanded, with more MoH hospitals providing pharmaceutical services such as parenteral nutrition, therapeutic drug monitoring, cytotoxic drug reconstitution, clinical and ward pharmacy services, and medication therapy adherence clinics and promoting quality use of medicine.

11.5.2.1 Human Resources

The production of pharmacists increased rapidly. The number of local pharmacy degree programmes increased rapidly to 22. The expansion was largely due to 17 institutions in the private sector; Chapter 8 discusses this phenomenon. The number of pharmacists per 10,000 population increased 4-fold within 14 years, namely from 1.02 in 2000 to 4.08 in 2014. The profile of the pharmacy workforce evolved rapidly (Figure 11.2). Two factors contributed to a rapid increase in the public sector workforce of pharmacists. First, in 2004, the government introduced a two-year period of compulsory service in the public sector for new graduates. Initially, there were concerns that this move would result in a shortage in the private sector, but it was expected that such a shortage would be short-lived, as market forces would continue to entice them to the private sector.

Figure 11.2

Number and ratio of pharmacists per 10,000 population.

Sources: Ministry of Health Malaysia, 1995; 1996; 1997; 1998; 1999; 2001; 2019a; Suleiman & Jegathesan, n.d.

However, a second factor intervened. The government amended its civil service conditions, resulting in pharmacists receiving higher starting salaries and better opportunities for career advancement. As a result, more pharmacists chose to remain in the public sector, and by 2009, the numbers in the public sector overtook those in the private sector. The sudden influx of new graduates was similar to that experienced in the medical workforce, discussed in Chapter 8. Its consequences for the public sector were similar – several administrative adjustments were required to accommodate the new graduates, who required supervision and monitoring during the first years of their service prior to full registration.

Meanwhile, the number of pharmacy assistants continued to increase, rising from 1.01 per 10,000 population in 2002 to 1.87 in 2017 (Figure 11.3). Until 2012, they were almost exclusively in the public sector, when the numbers in the private sector began to increase gradually. By 2005, the number of pharmacists had overtaken that of assistant pharmacists.

Figure 11.3

Number and ratio of assistant pharmacists per 10,000 population.

Source: Ministry of Health Malaysia, 2019a.

The increased availability of pharmacists produced other changes. First, their role in the public sector started to expand gradually to cover direct services to clients. Second, the simultaneous influx of large numbers of new graduates, both medical and pharmacy, stretched the capacity of the public sector to absorb them to the limit. This resulted in a push from the public sector into the private sector, in contrast to earlier years, when the attraction of the private sector had caused movement of both professions out of the public sector. Some indication of the stress to the private sector is the ongoing controversy between the pharmacy and medical professions regarding the separation of prescription and dispensing functions in the private sector. Pharmacists argue that this would be in the best interests of patients in order for them to obtain cost-effective medicines and avoid unnecessary use of medications and their side effects. The counter-arguments from the medical profession include: (a) that the relative scarcity of private pharmacies in rural areas would limit access to medicines, and (b) that ‘patients go to pharmacies to buy medicines after consulting the doctor once, and then continue buying prescription-only medicines without a prescription’. General practitioners (GPs) further acknowledge that in the face of multiple challenges, including a fee schedule that has been unrevised for 27 years, ‘most GPs survive because the sale of medicines provides a small margin of profit’ (Reference PhilipPhilip, 2019). The economic factors underlying the controversy are evident.

Box 11.4System observations: path dependency in dispensing practices

The parallel development of dispensing practices in public healthcare facilities and private clinics provides a good illustration of path dependency in health systems. The lack of pharmacists in the early years of the health system (Section 11.3.4) resulted in other health personnel taking on the dispensing role. In public healthcare facilities, economies of scale kept the dispensing role specialised such that assistant pharmacists (Section 11.4.4) and then pharmacists were later able to take on this role. In private clinics, however, prescription and dispensing remained closely linked in the absence of policy or systemic incentives to separate these functions.

11.5.3 Affordability and Pharmaceutical Pricing

In October 2006, in line with WHO recommendations, the Malaysian National Medicine Policy (NMP) (Dasar Ubat Nasional, or DUNas) came into force. It covers all aspects of medicines. The objectives of DUNas are to improve the health outcomes of Malaysians through:

1. 1. Promoting equitable access to essential medicines.

2. 2. Ensuring the availability of safe, effective and affordable medicines of good quality.

3. 3. Promoting quality use of medicines by healthcare providers and consumers.

Affordability is an important component of DUNas to ensure that cost does not become a barrier to equitable healthcare. To this end, DUNas encourages ‘Efforts … to promote healthy competition towards fair, transparent and sustainable cost-effective treatments’ (Ministry of Health Malaysia, 2012b).

Rising healthcare cost is a global phenomenon, albeit the rates grow differently by country. Malaysia’s medical inflation rates for 2019 were forecast to be about 5.7 times higher than that of general inflation (Aon, 2019). While there are many contributing factors to rising healthcare costs, higher drug costs is a significant factor. Drug affordability is a legitimate concern for patients with critical illnesses and those who require chronic therapy. Estimated conservatively, the health expenditure on medical goods in 2017 was 8%, or RM 4.55 billion of the national total health expenditure (Ministry of Health Malaysia, 2019b).

11.5.3.1 Public Sector

The public sector provides care for the majority of patients in Malaysia. For example, 70% of hospital admissions in 2017 were in public healthcare facilities. Hence the government budget allocation for medicine procurement is a concern. The total amount allocated for medicine procurement has remained about the same since 2014 (Figure 11.4) despite a yearly increase in public demand for drug treatment (Figure 11.5). In 2017, the allocation for medicine procurement for the MoH was about 10% (RM 2.38 billion) of the MoH operating expenditure.

Figure 11.4

MoH medicine expenditure, 2008–2017.

Source: Pharmaceutical Services Programme, Ministry of Health Malaysia, 2018.

Figure 11.5

Number of outpatient prescriptions received, 2011–2017.

Source: Pharmaceutical Services Programme, Ministry of Health Malaysia, 2018.

The government has to balance budget limitations against factors such as drug accessibility, value and (opportunity) cost and the rising demand for effective, quality and safe drug treatment. It does this through careful planning and procurement strategies.

The MoH practices an open tender policy for pharmaceutical products listed in the APPL (about 700 items determined by the MoH, which includes many items from the National Essential Medicines List) and the MoH National Tender (about 300 items). The MoH uses international best practices, for example, the WHO procurement process and workflows, for medicine procurement. Thus the process uses the indicative drug price based on market survey when calling for the open tender. This ensures that government central purchase obtains products that offer the best value. The MoH Procurement Board selects successful bidders after bids pass through the Technical and Financial Evaluation Committees. Only local purchase orders with a total value of less than RM 500,000 are exempted from open tender. Generally, generic medicines provide value while meeting budget constraints and public demand. Thus, in 2017, about 60% of drugs procured and dispensed were generics (30% local manufacture, 70% imported) (Pharmaceutical Services Programme, Ministry of Health Malaysia, 2018).

In its attempts to meet the increased demand for drug treatment, the government seems to have tried to keep the price it pays for drugs low to curb the escalation of its expenditure on drugs. However, the price the government pays for generic and originator drugs, although substantially lower than that charged in the private sector, has remained above the international reference median price (Table 11.1). Figure 11.5 shows that, from 2014 to 2017, despite no significant increase in its budget for medicine procurement, the MoH managed to provide an additional 8.2 million outpatient prescriptions. MoH management of budget disbursement in three-month staggered periods instead of annual disbursement to individual hospitals and clinics promotes prudent planning and more accurate forecast of local demand, thereby reducing the risk of drug shortage or wastage.

Table 11.1Price comparisons in private sector outlets

Source: Pharmaceutical Services Programme, Ministry of Health Malaysia, 2018.

As described, in the development since the 1990s, Pharmaniaga, although a private entity and concessionaire, continues to play an important role in logistics and storage service provision to MoH health facilities nationwide, even if the request is made by a health facility in a remote area. In addition, it handles the open tender processes on behalf of the MoH and the Ministry of Finance (MoF). As a local generic drugs manufacturer, Pharmaniaga may also bid for government procurement tenders. As Pharmaniaga is responsible for handling the bids, the issue of potential disadvantage to other competitors has been considered. The response to this was that bids by Pharmaniaga must be submitted at least two weeks before the close of tenders.

11.5.4 The Case of Right to Government Use

In early 2000, the costs of certain antiretroviral (ARV) drugs that were imported and under patent were so high that it limited the country’s ability to provide treatment to HIV-infected patients requiring it. In spite of negotiations, a suitable price could not be agreed upon. In 2003, the Malaysian government exerted rarely used powers to acquire the drugs through a tender to a local pharmaceutical company to import and supply selected generic versions of patented ARV drugs manufactured by the Indian company Cipla. This was possible by using a provision provided under the TRIPS agreement in line with the Doha Declaration 2001 by members of the World Trade Organization (WTO) and the provision of the Rights of Government under the Patents Act 1983 (World Trade Organization, 2001). The medication would be solely for the use of patients managed by MoH facilities. On completion of the ‘government use’ licensing period, the MoH was able to negotiate with the multinational companies for better prices and therefore no longer required the use of special provisions. A similar situation arose in 2017 for medication for hepatitis C; it is the subject of Case Study 12.1 in Chapter 12.

The government has indicated that it will not hesitate to use this mechanism in public health emergency situations where a large number of patients do not have access to affordable treatment. Malaysia is the first and one of only a few countries in the world to exercise this right to provide access to a patented product as part of its public health policy.

11.5.5 Pharmaceutical Trade Sector in Malaysia

Pharmaceutical products are important trade items for Malaysia. In 2017, their trade amounted to RM 6.45 billion or 0.36% of total trade. However, the import of pharmaceutical products was about six times larger than the total export value (Figure 11.6). This created a trade deficit of RM 4.6 billion in 2017. In accordance with the government’s Economic Transformation Programme, a project was implemented in 2010 to provide incentives for the local production of generics for export. Subsequently, the sales of generic and patented medicines as a percentage of prescription drugs have seen a reversal, with generics overtaking patented drugs in 2013 (Malaysia Competition Commission, 2017). The local pharmaceutical manufacturing sector started to pick up and saw a 63.7% increase in the export value from 2013 to 2017 compared to a 31.3% increase in the value of imported medicines (Figure 11.6). The increased export value for formulated products (medical products) for human use (Table 11.2) contributed 81.0% of all pharmaceutical products export in 2017.

Figure 11.6

Export and import value of pharmaceutical products to Malaysia, 2013 and 2017.

Source: Department of Statistics Malaysia, 2018.

Table 11.2Export and import value of pharmaceutical products to Malaysia by product category, 2013–2017

Source: Department of Statistics Malaysia, 2018.

11.6.1 What Went Well?

• The medical products subsystem at various times in development:

  1. ◦ Responded to demands from rapidly expanding health services and more variety and higher costs of internationally available medical products.

  2. ◦ Dealt with hazards and stresses such as trade in illicit and dangerous drugs, dumping of poor-quality and unsafe medicines, misuse and abuse of allopathic and traditional medical products, internationally rising costs of pharmaceuticals, and patent protection.

  3. ◦ Served its purpose despite facing constraints, including human resources and budgetary limitations.

• The health system successfully improved access, safety and quality of imported and local products, quality of local production, and cost control through incremental steps in strengthening:

  1. ◦ logistics and production capacity,

  2. ◦ legislation, monitoring and enforcement,

  3. ◦ education and negotiation.

11.6.2 What Did Not Go So Well?

• The inability to moderate the high and increasing cost of medical products in the private sector.

11.6.3 Trends and Challenges

• Challenges in traditional medicines and health supplements:

  1. ◦ Adulteration

  2. ◦ Inappropriate marketing and use

  3. ◦ Sale as health foods to bypass regulation of medical products

• Pressure from the pharmaceutical industry for patent protection.

• Implementation of price control tools.

• National formulary for all public sector health facilities to enable them to have economies of scale in purchasing and to have uniform policies such as antibiotic policies.

12.2.1 National Governance Context

The Malaysian Constitution provides a federal type of government, with division of powers between the federal and state governments. At the federal level, the legislature consists of a lower House of Representatives, elected through nationwide elections, and a partially appointed Senate. Each state has its own State Assembly elected by statewide elections. The parliamentary type of government has an executive (Cabinet), headed by a prime minister who is a member of the lower house and a number of ministers. The hereditary Malay heads (Sultans) of some states elect from among themselves a monarch (Supreme Ruler) who serves for a fixed term. The monarch has limited powers and follows the advice of the prime minister of the day. The rulers, on the advice of their governments, appoint the members of the independent judiciary, both at federal and state level. While some powers are exclusive to either the federal or the state governments, there are some overlapping areas where powers are conjoint. The federal government has powers concerned with health and the provision of health services and others relevant to health such as the environment, labour and education (Commissioner of Law Revision, 2014), whereas states have powers over land.

Malaysia adopts a holistic approach wherein health policies are formulated and developed within the context of wider major national development policies set by the Prime Minister’s Department (PMD) and Cabinet and articulated in various Malaysia Plans. Health professionals in the Ministry of Health (MoH) have the primary responsibility of advising the government on health priorities and formulating health programmes and interventions according to these priorities. Achieving balanced development with greater equity and poverty alleviation has been a national aim, with the reduction of differences between groups of people and regional areas a key priority. Another aspect of priority-setting has been the need to balance health service development with human resources availability and fiscal constraints (Economic Planning Unit, 1991; 2015; Chapters 3–9). National priorities and health needs have evolved as economic and social development took hold with growing urbanisation (Chapter 3). For example, the Eleventh Malaysia Plan (2016–2020) moved priorities from eradicating poverty to improving the living conditions of the 40% of all households that have the lowest income (Economic Planning Unit, 2015). The MoH policies responded accordingly.

12.2.2 MoH Organisational Structure

At federal level, the MoH, headed by a Cabinet-level minister, has two arms. The administrative arm, headed by the Secretary General and staffed by civil servants from the country’s general public civil service, is responsible for public service personnel administration, finance and procurement. The health professional arm, headed by the Director General (DG) and staffed by healthcare professionals, focuses on planning, implementing and evaluating service delivery and the wider concerns that affect the health of the community. It appears that areas under the DG’s responsibility tend to be concerned with the whole system beyond the health services provided by the MoH, while those under the more direct administration of the Secretary General tend to relate to the provision of services by the MoH and public service administration.

The organisational structure of the MoH follows the conventional separation of public health and community-based services from medical and hospital services, with separate areas of responsibility for research and technical support, including planning, engineering services, the National Institutes of Health, dental care, and pharmaceutical goods and supplies. Each state has a state-level health department responsible for administration and delivering services, and its organisation reflects the conventional separation of public health and community-based services from medical and hospital services (Ministry of Health Malaysia, 1975; 2018). There are smaller administrative entities at district and hospital levels. As described in Chapters 4, 5, 6 and 8, the evolution over the past 60-year period has seen growing professional and managerial competence, beginning at the federal level and gradually trickling down to the district and hospital levels.

12.3.1 Inter-ministerial Leadership

The MoH is the major source of technical expertise for health. It formulates and administrates health-related legislation and regulations, provides training for nursing and other allied health professional personnel and is the major provider of health services in Malaysia. However, health is dependent not merely on health services but also on what people do and their work and living conditions. Consequently, the MoH often lacks both the direct authority and supervision of substantial areas of relevance to health risks management and their impact on health that fall under the responsibility of other ministries or agencies such as environment, transport or food services. This diversity of authority and responsibilities requires the MoH to provide, at times, leadership and technical support in collaborative approaches with other federal and state agencies and civil society in the pursuit of policies and practices that enhance the health status of Malaysians.

Historically, several other ministries have played influential roles in health development. The PMD plays a major role in developing national policy that guides health policies and translating it into five-year plans with mid-term reviews and longer-term outline perspective plans. This process enables performance evaluation and corrections. The Ministry of Finance addresses fiscal needs from development and operational demands. As MoH revenue amounts to only a small fraction (3% in 2016) of its operational expenditure, it is dependent on the fiscal resources of the federal government through the Ministry of Finance (Ministry of Health Malaysia, 2018; Chapter 9). The role of the Ministry of Education (MoE) has expanded from training medical students to include the training other health professionals. The MoE also administrates a number of university teaching hospitals and has partnered with the MoH in providing health-enhancing services and promoting healthy practices in school-age children. Finally, co-ordination across different levels of government has also been important, with federal, state and local governments sharing responsibilities in areas such as the promotion and maintenance of healthy conditions at a local level, such as the preparation and sale of food in urban areas.

New and emerging challenges to public health have triggered changes in the roles and inter-relationships between ministries. For example, as health concerns related to environmental, occupational or lifestyle issues rise in importance, the corresponding ministries have an increasing responsibility for health. However, there are examples where professional specialisation in the relevant ministries has created gaps in their ability to respond. The MoH has stepped in to address these gaps or ensure proper ownership by other ministries. For example, the professional strength of the agencies concerned with the environment (e.g. the Department of Chemistry) led to a focus on chemistry rather than on bacteriology. In the case of labour, safety concerns focused on risks from mechanical devices and not on exposure to and contamination by biological agents. The MoH supported the relevant ministries in developing the needed expertise.

Although the MoH is the acknowledged leader for issues related to health, in practice, leadership has taken on different forms and has been manifested by different institutions. For example, Chapter 7 provides an example where the MoH provided leadership by facilitating other agencies that had the primary responsibility of providing safe water and sanitation to develop the professional competence required to perform their function adequately. Similar examples are evident in the management of other environmental and occupational health risks (Chapters 4, 6 and 7). As other ministries and agencies acquired greater capacity to address the changing environmental, labour and social scene, the role of the MoH evolved and became a supportive one.

Sometimes leadership is a shared role. For example, universities under the MoE are responsible for the academic training of medical practitioners. However, the MoH, as the leading provider of healthcare, takes the lead in defining the competencies required in the medical workforce, while the universities take the lead in designing and implementing the curriculum. However, the MoH provides much of the practical training and internship of doctors in its public hospitals and is therefore the final authority to decide whether the new doctor is competent to practice without supervision (Chapter 8). Civil society has also demonstrated leadership in health. Chapter 6 provides examples of situations where non-governmental organisations (NGOs) provided leadership for successful advocacy for national policies and programmes to tackle tuberculosis and HIV/AIDS.

12.3.2 Leading and Governing Service Delivery in the Public and Private Sectors

The private sector has a significant role in the delivery of healthcare in Malaysia. An important governance question is whether the provision of health services is a public or a private matter and the role of government in its provision and financing. The nature of health services does not make market mechanisms effective to ensure efficiency and social, or even private, satisfaction in meeting health needs. Much of healthcare has the characteristics of what have been termed public goods,¹ which makes market competition an inadequate means of achieving efficiency or ensuring equity in their distribution in view of income inequalities and poverty. Further, health services, like education, have attributes that can give them social merit that society needs to determine independently of preferences determined by price and consequently the living standards of more than one generation. Further, the health service ‘market’ is characterised by commonly designated ‘market failures’ that preclude assumptions regarding the maximising of consumer utility (or welfare) and efficiency in the allocation of resources and their use. Among other attributes, the health ‘market’ is characterised by few providers, especially in the case of hospitals, with restrictions to entry due to licensing and other constraints; prices that are sometimes determined by providers or insurers; asymmetry of information between consumers and providers, as the consumer is dependent on the supplier to determine services received; and, as previously mentioned, considerable externalities, especially in the case of infectious diseases. These characteristics of the health services ‘market’, especially in the case of services provided by the private sector, do not allow the efficient performance of social objectives of consumer sovereignty and efficiency (Reference Martins, Courtney and BriggsMartins, 2004).

Thus governance of the health system in Malaysia has to address the balance between public and private provision of services, their relative costs and equity in their distribution. First, the relative scarcity of medical personnel and their concentration in urban centres led to the provision of public sector primary healthcare in rural areas, where most people lived, by allied health personnel. This was a low-cost but effective delivery of basic healthcare. Complemented by environmental services, it contributed to improved equity in access to health services (Chapters 3, 4 and 8).

As medical personnel became more abundant and people more urbanised, with easier geographical access to both public and private health services, the provision of lower-cost public services still played the important function of benchmarking the price of private services, keeping private fees in check. However, to retain medical personnel, the governance of public services had to keep the remuneration of medical personnel in the public sector at an acceptable level (Chapters 8 and 9). These balancing efforts have kept total health expenditure in Malaysia at the middle level of 4.0% of the gross domestic product (GDP) in 2014, compared with its neighbouring countries – 6.5% in Thailand, 4.9% in Singapore and 2.8% in Indonesia (Ministry of Health Malaysia, 2017) – and added about 15 years to the life expectancy of Malaysians (Chapters 3 and 9).

The governance of health services raises some potential conflicts of interest for the MoH. An obvious one is that the MoH is both a regulator and a provider of services. This governance issue is only partly addressed by the establishment of state administrations of public sector health services that are accountable and subjected to oversight by the central administration of the MoH. However, the MoH is, in turn, subjected to oversight by agencies in the PMD and the Ministry of Finance.

In addition, a number of governance issues arise from the government-stated interest in the promotion of the private sector in general and private health services in particular. The government has nominated health as one of the National Key Economic Areas. Although a number of economic activities are included, such as the production of pharmaceutical and medical devices, with some emphasis on their economic and export value, an area more directly related to health services is medical tourism (Prime Minister’s Department, 2017). The Malaysian government has promoted medical tourism since the late 1990s (Reference Ormond, Wong and ChanOrmond et al., 2014; Reference Chandran, Mohamed, Zainuddin, Puteh and AzmiChandran et al., 2017). It is fostered by the Malaysia Healthcare Travel Council (MHTC), an initiative of the Ministry of Finance. The council’s membership also includes the ministries of relevance to tourism, the MoH, and other agencies such as the Association of Private Hospitals of Malaysia (Malaysia Healthcare Travel Council, 2020). There is no obvious evidence of the direct relevance of medical tourism to the health of Malaysians, as its objective is an economic one. This is reflected in the absence of any apparent reference to medical tourism in the annual reports of the MoH (e.g. Ministry of Health Malaysia, 2018). There is not much specific information on the value of medical tourism and its contribution to economic activity. An estimate by the MHTC for 2017 of the value of medical tourism was that it represented the equivalent of about 0.1% of the value of Malaysia’s exports in that year (Malaysia Healthcare Travel Council, 2017; Malaysia External Trade Development Corporation, 2018).

However, this economic interest has led to pressure on the MoH to reduce the regulatory burden on private health services in its administration of the Private Healthcare Facilities and Services Act. In this context, a study mandated under the Tenth Malaysia Plan to modernise business regulations conducted a regulatory review with the aim of reducing unnecessary regulatory burdens on private hospitals (Malaysia Productivity Corporation, 2014a). The review focused on the private hospital sector, as this is deemed a high-value-added, high-knowledge-based and growing sector. It found that regulations covering private hospitals were excessively prescriptive and made several recommendations for reducing the regulatory burden. It is noteworthy that the annual report of the same agency – related to the Ministry of International Trade and Industry – for 2013–2014 mentions rising costs and innovation as the major issues to be addressed by private hospitals and makes no mention of the burden of regulations (Malaysia Productivity Corporation, 2014b).

The regulation of medical personnel has been an important point of consistency across the public and private health sectors. Health services are dependent on the competence of medical, nursing and other professional personnel. Malaysia uses the mechanism of licensing via statutory bodies to manage these standards of practice, and this process has evolved and became more comprehensive over time (Chapter 8). For example, the Nurses Act 1950 provided for a Nursing Board to supervise the training and registration of nurses and oversight of their practice (Reference Chong, Sellick, Francis and AbdullahChong et al., 2011). The Medical Act 1973 gave the Malaysian Medical Council the authority to evaluate the qualifications of medical practitioners and their registration (Malaysian Medical Council, 2018). This was important because of the past shortages and recruitment from countries with varied training and degrees of competence. The licensing and/or registration of other health professions has continued over the years to ensure appropriate and safe professional practice (e.g. Allied Health Professions Act 2016) (Reference LimLim, 2016).

12.3.3 Regulations for Health and Safety

In the health sector, Malaysia uses regulation and licensing for two major purposes. The first is to manage threats to community health arising from the spread of disease or deleterious elements in the environment in which people live. The second is to protect the community from fraudulent or potentially harmful practices by healthcare providers or through the sale of medical and food products. The regulations give legal authority to various agencies for their enforcement, with sanctions for their infringement.

Initial regulatory activity by the MoH addressed infectious disease (Chapter 6), medical personnel (Section 12.3.2) and medical products (Chapter 12). In later years, however, as urbanisation and industrialisation increased the health risks of water supply contamination, changes to the Constitution allowed the federal government and the MoH to play a greater role in water supplies and sewerage and their regulation (Water Services Industry Act 2006) (Reference WahabWahab, 2011; Reference Pidgeon, Pidgeon, McDonald, Hoedeman and KishimotoPidgeon, 2012). The MoH plays an active role in the National Drinking Water Quality Surveillance Programme (Ministry of Health Malaysia, 1998). The growth in the commercialisation of food supplies, including international trade, has added to health risks in food supply and consumption, leading to the strengthening of the Food Act 1983 and its regulations.

Most Malaysians are of working age and are employed in a wide range of activities with varied degrees of health risk and disability risk. Consequently, occupational safety is a major factor in the maintenance of health. The Occupational Safety and Health Act 1994 aims at maintaining safe working conditions and applies sanctions for adverse practices. Although the administration of related regulations and surveillance lies with the Ministry of Labour, the MoH remains concerned about the surveillance of occupational diseases in order to identify the causes and sources that can direct remedial action, in addition to the promotion of the health of the large labour force in health services (Ministry of Health Malaysia, 2018).

Malaysia has used health legislation and regulation sparingly, perhaps in part due to limitations in institutional bandwidth and capacity. The lead time for enacting and enforcing new legislation is lengthy, taking five or more years for food legislation, for example. This indicates the complexity of the processes, which include stakeholder engagement, legal expertise and availability to draft the legislation, and developing the enforcement capacity and mechanisms for implementation. Such capacity might require financial resources, digital monitoring, laboratory services, the establishment of procedures and guidelines, and the training of enforcement and prosecution staff. In addition, the nature of the imperatives for legislation influenced political will and support, which in turn influenced the priority of enacting and implementing legislation effectively and the system capacity to do so.

Table 12.1 illustrates this through contrasting examples of the development of legislation to safeguard against hazards in food, where strong foreign trade imperatives proved much stronger than domestic imperatives that involved balancing health concerns against the growth of local food services.

Table 12.1Differing imperatives influenced the system behaviour in formulating health legislation

While it is important to allow sufficient time to garner stakeholder support and build system capacity, long lead times in developing legislation and regulation can be detrimental. A problem may develop in the intervening period, resulting in the need for repeated re-drafting of legislation. It weakens governance capacity and engenders frustration among groups experiencing negative impact and among enforcement authorities. An example from Case Study 5.1 in Chapter 5 is the long delay in enacting legislation to govern the behaviour of third-party agencies that serve as intermediaries between employers and healthcare providers for their employees.

12.3.4 International Collaboration

As with most developing countries, the development of Malaysia’s health system has had some external support, specifically from the multilaterals. The World Health Organization (WHO) has been a source of technical advice on the management and prevention of both communicable and non-communicable diseases as well as health personnel training and the organisation of community- and hospital-based services. Malaysia has also collaborated with international financial institutions such as the Asian Development Bank and the World Bank. International support for the Malaysian health system has been predominantly technical in nature, with limited financial support, to cover some infrastructure development rather than for the delivery of programmes. As discussed in Chapter 6, the limited reliance on international financial support contributed to the ability of the MoH to design programmes based on national priorities and directions, integrating new initiatives into existing ones rather than developing parallel initiatives according to external priorities.

The activities of the Institute for Medical Research (Chapter 6) include early examples of Malaysia’s international collaboration on research into tropical disease control and professional training for countries in the region (Ministry of Health Malaysia, 1980). A more recent example is the establishment of the ASEAN Risk Assessment Centre for Food Safety (ARAC) to foster collaboration among Association of Southeast Asian Nations (ASEAN) members to improve food safety (Ministry of Health Malaysia, 2018).

The wide range of Malaysia’s engagement in international collaboration comprises the continuing contributions of the WHO Collaborating Regional Centre for Research and Training in Tropical Diseases and Nutrition, and the Collaborating Centre for Ecology, Taxonomy and Control of Vectors of Malaria, Filariasis and Dengue, as well as collaboration in health systems research, among others (World Health Organization, 2002; Reference Barraclough and PhuaBarraclough & Phua, 2007; Ministry of Health Malaysia, 2018). Other areas of international collaboration involve co-operation with and support of ASEAN countries on a range of health concerns (Reference Barraclough and PhuaBarraclough & Phua, 2007). In addition to food safety, these activities include the control of infectious diseases and oral health, as well as other ASEAN clusters of co-operation on issues such as healthcare coverage and access, human resources and health technology assessment (Ministry of Health Malaysia, 2018).

12.4.1 Vision and Programme Setting

The national priorities set by the PMD and the Cabinet and articulated in various Malaysia Plans guide health priorities. For example, a major national aim was to achieve balanced development with greater equity, particularly between urban and rural areas, and poverty alleviation (Chapter 3). Top leadership in the MoH contributed to the ability of the health sector to translate national goals into a health sector vision and inculcate basic values that characterised the delivery of health services in both the public and private sectors. An example of the contribution of personal leadership is, for example, the leadership of the Health DG in the 1970s, who translated the Alma Ata vision for primary healthcare into the Malaysian context, as described in Chapter 4. In later eras, successive DGs translated the national emphasis on improving quality of service into a systematic nationwide programme and culture in the public sector health services, as illustrated in Chapter 5. Leaders demonstrated their commitment to collaborating with peers across organisational boundaries and recognising leadership qualities in their subordinate staff and supporting them. Box 12.1 illustrates how persons occupying top positions in the MoH at various times viewed their own contributions to leadership.

Leadership also emerged at various levels of the MoH organisation in response to specific challenges, as illustrated in the example of the introduction of the human papillomavirus (HPV) vaccination programme (Table 12.2). Leadership has also emerged from the private sector health service. For example, it was a general practitioner (GP) from the private sector who spearheaded the development of family medicine as a speciality (Reference RajakumarRajakumar, 1984).

Table 12.2Illustrative features of leadership during Malaysia’s experience in introducing HPV immunisation

Source: Reference Buang, Ja’afar, Pathmanathan and SaintBuang et al., 2018.

Most health system programming has been concerned with the organisation of services in the public sector in accordance with national priorities, as detailed in the previous chapters. The health requirements programming in Malaysia follows a top-down and bottom-up approach with a reiterative consultative process that involves a wide variety of officers at national, state, district and hospital levels. MoH programme directors in the various divisions and institutions raise and discuss issues, while similar processes occur at state level. This process involves reviewing and assessing health conditions and trends in Malaysia and identifying the driving factors in order to formulate responses. Current programmes are evaluated, with changes planned to meet evolving circumstances (e.g. Ministry of Health Malaysia, 2012; 2018). Proposed programmes and projects are also evaluated, and those involving large expenditures undergo further assessment for compatibility with development budget estimates. They are submitted for review and approval to the Economic Planning Unit in the PMD for financing and implementation during the period of the proposed Malaysia Plan (Reference Suleiman and JegathesanSuleiman & Jegathesan, 2000; Ministry of Health Malaysia, 2018).

Issues and priorities identified at the national level are cascaded down to state and district level, which in turn identify local issues and merge them into the national framework and cascade them up to national level for review by a committee of senior managers, with the Division of Planning as the secretariat. This has the advantage of considering perceived major national issues in conjunction with the benefit of emerging local conditions and constraints. In addition, it is a mechanism for developing leadership and governance skills at various levels of the MoH system. However, this process may lead to delays between the identification of health risks and the implementation of responses, such as in the case of dengue and diabetes control (Institute for Public Health, 2015).

12.4.2 Data and Evaluation

Governance is first and foremost about achieving results. Monitoring is crucial for identifying constraints encountered in the short term and the attainment of outcomes in the longer term. Reliable and relevant health information is essential in the performance of this governance function (Chapter 10), and relevant follow-up action is a critical partner to monitoring and evaluation. Monitoring and evaluation could be considered necessary but are not sufficient conditions of progress. For example, there has been a lag between monitoring and action in the incidence of dengue. Infectious diseases monitoring has shown a substantial rise in the incidence of dengue since 2000. Although case fatality rates declined due to medical treatment, preventive action lagged and incidence rates were 10 times higher in 2016 than in 2000 (Ministry of Health Malaysia, 2018). Malaysia’s systematic planning and evaluation of health development uses information from regular population censuses and comprehensive registration of vital statistics that identifies the population groups most at risk and what degree of progress, or otherwise, has been made over time. Another strength has been the wider people-centred development approach that focused on poverty and human capital, including health, with the collection of data on living conditions (e.g. Department of Statistics, 1959) that identified the population groups most at risk. These were complemented by the registration of health professionals, inventories of health facilities and health service activity information, especially in the public sector, which provided most services. However, it was their analysis in relation to the population that provided the basis for evaluating the results and relative progress. The National Institutes of Health provide research and programme evaluation studies that contribute to the information database. Requests for many of the National Institutes of Health studies come from the MoH, and therefore have a direct link to decision-making.

The evaluation of data and the use of the findings for management purposes demonstrated the importance of health information and research, creating a feedback loop that has led to further investments and improvements in data quality and relevance. In early times, data collection and processing was often carried out by manual methods, before the wider use of computers and what became known as IT (information technology). The substantial investment in the use of IT in managing health services has improved the storage of, access to and analysis of a wide range of health information for monitoring and evaluating progress (Ministry of Health Malaysia, 2005; 2018; Chapter 10). However, it is important to note that improved data collection alone does not guarantee health improvements. The substantial IT thrust has coincided with an increase in the incidence of some non-communicable diseases (e.g. diabetes) during the 2000s and 2010s, stagnation of infant and maternal mortality rates and slower improvements in life expectancy (Chapter 3). Effective ways of understanding and using data to meet these new health challenges need to be developed.

The governance of the health system entails assessment of the current and emerging technologies and practices to evaluate effectiveness, relevance to local conditions and efficient provision. In earlier years, Malaysia depended largely on expertise from international agencies such as the WHO to inform the selection and use of technologies. Examples are the very early adoption of a list of essential drugs and the selection of vaccines to be included in universal childhood immunisation programmes. However, as the complexity of health technology increased and new hospitals were built based on external expertise, technology assessment and use in the Malaysian context became more imperative (Reference SivalalSivalal, 2009; Reference Roza, Junainah, Izzuna and NurhamiRoza et al., 2019). The MoH established a section for assessing new technologies and reviewing current ones (Malaysian Health Technology Assessment Section, or MaHTAS), and its process relies on systematic reviews of intelligence gathered from other reliable sources and its own evaluation (Ministry of Health Malaysia, 2018). The outputs inform the development of clinical practice guidelines and the purchase of costly technology or medical products by the MoH (Chapter 5). Other examples of the evaluation and use of findings include the assessment of the cost-effectiveness of some of its services, such as neonatal intensive care and diagnostic imaging services, and the effectiveness and improvement of clinical services such as renal dialysis and cataract surgery (Ministry of Health Malaysia, 2002; 2005; Chapter 5). Another example is the evaluation of services that have been outsourced, such as hospital laundry and cleaning services, where the performance of contractual services is a regular feature and has shown increased levels of contractual compliance (Chapter 7).

12.4.3 Accountability

Accountability is an essential feature of governance, although the concept is difficult to define. Accountability involves reporting the actions taken to another who is in a position to assess their appropriateness (Reference MulganMulgan, 2000). Accountability processes are learning opportunities for corrective action or appropriate shifts. In the Malaysian health system, accountability takes place at different levels and several forms. For example, compliance with rules and regulations, or spending within set budgets, is a form of accountability. Another example is the accountability of professional and other standards of healthcare practice exercised by professionals to their respective statutory registration boards, as described previously. On a different level, accountability is concerned with enhancing the performance and responsiveness of a health service to health conditions and the expectations of the public. This happens on a personal level, through complaints either via official pipelines or the mass media. Alternatively, accountability to the public can occur through political channels.

Several institutional mechanisms support accountability in the health sector. Performance reviews of the various programmes and services take place within the MoH system in a quasi-hierarchical manner, from single service units to state and national level. Accountability of performance and responsiveness to health needs also takes place during the preparation for each five-year Malaysia Plan and their mid-term reviews (Ministry of Health Malaysia, 2012; 2018), reviewed by the PMD and Cabinet. In turn, the Cabinet is accountable to parliament and it to the electorate. At micro and intermediate level, accountability to the public occurs through the mass media, whereby the MoH monitors and reviews every complaint appearing in news media. MoH procedures require a response to the complaint or appropriate remedial action.

Non-regulatory mechanisms can also promote accountability, as seen in the surveillance of practice and follow-up remedial action, particularly in the public sector (Chapters 4, 5 and 7). Examples include the Quality Assurance Programme (QAP) established in the MoH in 1985 that provided leadership to foster service quality (Ministry of Health Malaysia, 1998; 2018); the adoption of the International Organisation of Standardisation (ISO) (9001 version) Quality Management System (QMP) in accordance with government policy (Reference Hashim and IbrahimHashim & Ibrahim, 2016; Ministry of Health Malaysia, 2018); and the establishment of the Malaysian Society for Quality in Health (MSQH), which provides voluntary accreditation for public and private hospitals using national standards to assess the level of performance through external review and encourages continuous improvement of practice (Malaysian Society for Quality in Health, 2019). Most MoH hospitals have been accredited (Ministry of Health Malaysia, 2018), as have many in the private sector (Reference Aziz and AzizanAziz & Azizan, 2013). The evolution from regulatory to non-regulatory mechanisms reflects the tacit acknowledgement that regulation is suited only to weed out extreme cases of poor quality (the ‘bad apples’). Continuing improvement of the systems-wide quality of healthcare requires systems-wide incentives, including monitoring and feedback, professional and managerial human resources competencies and the development of an organisational culture that values quality.

A systemic challenge to accountability in the public health system is that the MoH is simultaneously the regulator and the provider of public health services in Malaysia. One illustrative example of potential conflict is that all the regulatory boards that govern health professionals have the DG of the MoH as chairperson and the respective programme director as secretary. However, the DG and the respective directors are also the heads of the respective services provided by the MoH, thereby posing a challenge to preserving the principles of accountability.

12.4.4 Structural Challenges and Governance Responses

The divisions of expertise and responsibility necessary for a functional health system also tend to foster the development of silos. The MoH employs task forces and committees that cut across divisions to mitigate this problem. The task forces deal with issues that require time-limited activities, while the joint or national committees deal with issues that require continuing collaboration. Changing demands on the health system have dictated different responses. For example, when maternal and child health were the focus, obstetricians and paediatricians from hospitals joined public health professionals in committees for the investigation of maternal deaths. As the focus moved to non-communicable diseases and emerging infectious diseases, a plethora of other committees and task forces combined the talents of clinicians, epidemiologists, laboratory specialties and healthcare managers to develop national strategies or action plans, as illustrated in Chapters 5 and 6.

Anecdotal evidence suggests that task forces that had to produce tangible products within short timeframes were very successful, as evidenced in the examples in the chapter on disease control (Chapter 6). Committees that had continuing responsibilities over time, such as the MoH/MoE joint committee for school health, tended to become lethargic or dormant until energised periodically by having to respond to new leadership or focus on a new challenge, as seen in the example of introducing the HPV vaccine for schoolgirls. Nonetheless, these committees appear to foster institutional memory that can facilitate rapid and effective collaboration across divisions (Reference Buang, Ja’afar, Pathmanathan and SaintBuang et al., 2018).

Another challenge is that human resources in the MoH are part of the larger civil service of Malaysia and are governed by the large and rather unwieldy bureaucracy. As such, the MoH has limited flexibility in adjusting employment conditions to the needs of healthcare services. For example, posts and promotion criteria adhere to general civil service rules (Institute of Health Management, 2006). Another example is the prolonged negotiations required to provide special incentives for selected categories to address brain drain to the private sector. This was partly due to concerns that other categories of professionals in the same grade would demand similar incentives, although there was no reason to provide them.

12.4.5 Leadership Development

Although there is no empirical evidence, it is possible to postulate that several factors have contributed to the development of leadership at various levels in the health system. First, the civil service system of career progression requires, as a precondition to promotion, participation in management training programmes that raise awareness of leadership and its functions and the opportunity to bond with fellow officers from other ministries, thereby facilitating future networking. Second, career progression provides officers with the opportunity to occupy leadership positions at successively higher levels in the system (namely district, state and then national levels), thereby providing invaluable experience in communicating and collaborating with other agencies at progressively more complex levels. Third, within the MoH itself, the system requires clinical specialists, who previously focused only on their own patients, to take leadership for their clinical speciality across the state or the whole country. Participating in cross-disciplinary task forces, they acquire leadership competencies. However, to some extent, clinicians are disadvantaged compared to their colleagues in public health, as the latter acquire managerial experience throughout their career, starting from managing district-level entities and progressing to larger entities. In contrast, clinicians acquire exposure to managerial functions relatively later in their career. Fourth, the devolution of decision-making functions in programme formulation, as described above, provides the opportunity for nurturing leadership within the system.

12.6.1 What Went Well?

• Despite the highly centralised structure of the healthcare system, it

  1. ◦ contains both top-down and bottom-up systems for planning, evaluation and implementation,

  2. ◦ has good internal feedback loops, and

  3. ◦ has adaptive capacity at implementation level.

• The system promoted and supported leadership development.

• The centralised nature of the system addressed concerns of equity across administrative state boundaries.

12.6.2 What Did Not Go So Well?

• Limited capacity to deal with determinants of health that are under the purview of other sectors.

• Governance structure and inadequate information limited the ability to respond to some social and environmental issues arising from rapid urbanisation, such as:

  1. ◦ health in pockets of urban poverty,

  2. ◦ the health of marginalised groups, and

  3. ◦ loss of trust in authority and establishments, giving rise to anti-vaccination movements, etc.

• The combination of the roles of provision and governance of healthcare in the public sector creates the appearance of conflicts of interest, such as:

  1. ◦ regulation of professional bodies, and

  2. ◦ governance of private sector healthcare.

12.6.3 Trends and Challenges

• The rapid rate of change of the societal ecosystem and technology presents challenges to governance and leadership.