Public-Private Integration in Health Care Delivery - Past and Present

Dr Rozita Halina Tun HusseinDeputy Director

Unit for National Health FinancingPlanning and Development Division

Ministry of Health, Malaysiarozitahalina@moh.gov.my

Symposia on Public Private IntegrationPublic Health Conference

12th July 2011

Theoretical Framework

Integrated Health Services• DefinitionThe organisation and management of health

services so that ...– people get the care they need,– when they need it,– in ways that are user-friendly,– achieve the desired results and– provide value for money

(WHO Tech Brief No.1, May 2008)

• Means to an end, not an end in itself

Integrated Health Services• User – health care that is seamless, smooth and easy to

navigate continuity of care, health worker aware of patient’s health as a whole, not just 1 aspect

• Provider – separate technical services and administrative support systems are provided, managed, financed and evaluated either together

- Important with increasing specialization• Senior health managers and policy makers – decisions are not inappropriately compartmentalised, consider different technical programmes, taking into account the network of public, private and

voluntary health providers, inter-sectoral opportunities

Role of the Private Sector in Malaysia

• Malaysia has always had private health care– During colonial times prior to Independence– During economic boom– Now as engine of growth– Future – greater integration and synergism

• Government health care delivery has been stronger than private health care sector, appreciate private sector growth

• Idea of public-private integration is not new in Malaysia (Acknowledgment – Relevant MOH colleagues)

Past Efforts in Public- Private Integration

PAST: Reduction of Maternal Mortality

Working with Traditional Birth Attendants (TBA)• 1960s and 70s – strong political commitment to

reduce MMR and ensure Maternal and Child safety at delivery

– Recognise the time lag for government to train own skilled birth attendants (SBA) such as mid-wives

– Recognise public’s preferences at that time• Registration of TBA• Training of TBA

(Acknowledgment – Yadav, 1987 & Dato’ Dr Narimah Awin)

PAST: Reduction of Maternal Mortality

• Monitoring and supervision of TBA after training– All mothers using TBAs screened at health centres –

assessed for risk factors – Public health nurse kept records of all mothers and

deliveries managed by TBAs– Sterile midwifery kits and medicines exchanged at

the health centres for free– Monthly meetings between TBAs and public health

nurses– Dual attendance of deliveries – government midwives

cut umbilical cords

• Improvement in mortality rates particularly MMR

PAST: Quality Improvement Initiatives• QA/QI – strong focus of MOH• Sensitisation and training of private hospitals• 1996/97 – voluntary national accreditation

programme – MSQH – same standards for both public and private hospitals– Pioneered by MOH, Association of Private Hospitals

Malaysia (APHM) and Malaysian Medical Association (MMA) – contributed funds to run programme

– Good cross-fertilisation and learning – surveyors are from both public and private hospitals

• Benchmarking of private hospitals – NPC, MOH• APHM annual conference – participation of

government & MOH – QI, clinical governance, corporate governance

Facilitating Environment

Economic Transformation

Program (ETP)

• New Economic Model – a high income, inclusive and sustainable nation•March 2010

Government Transformation

Programme (GTP)

• effective delivery of government services•January 2010

Transforming the Nation towards Developed Nation Status by 2020

1MALAYSIAPeople First, Performance Now

April 2009

10th MP (June 2010) + 11th MP

1Care for 1Malaysia

Transforming The Nation

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Public Sector Transformation1. Create a citizen-centred public service

2. Reduce size of government – lean government, reduce overlapping roles and functions

3. Improve skills of the workforce

4. Focus more on results oriented spending, look into areas of cost-savings and efficiency of resource use

5. Strengthen govt’s facilitative role - collaborate with the private sector and support private sector growth

6. Expand private delivery of public services – allow competitive access to public funding e.g. in health care, technology support

7. Enhance public agencies to drive growth

1. Specialising the economy - high value-added, innovation-based, strong growth potential, GTP → enabling environment → internally-competitive, appropriate soft & hard infrastructure knowledge economy

2. Improving the skills of the workforce – specialised & skilled labour moving up the value-chain, increase productivity, social and private returns to education & skills upgrading

3. Making growth more inclusive – Strong inclusiveness policies, equity, improved social protection → helping household cope with poverty through health care

1. Bolstering public finances – broaden the country’s narrow revenue base, lessen subsidies, reduce the crowding-out of private initiatives, shift expenditure to areas of specialisation, skills & inclusiveness 14

Economic Transformation Programme

National Key Economic Areas (NKEAS)NKEAs - drivers of economic activity that has the potential to

directly and materially contribute a quantifiable amount of economic growth to the Malaysian economy

Current Efforts in Public- Private Integration

PRESENT – Govt or MOH Investments• Medical tourism - MHTC– 1-stop centre on hc travel

– Private hospitals - at least national level accreditation– Government incentives – tax exemptions on private capital

investments for medical tourism• Outsourcing with Contractual agreements (SLA) - e.g.-

– 5 hospital support services and catering of food– Pharmaceuticals with Hospital Pharmacy Information System

(drug inventory programme for MOH hospitals)– Health care services

• when machine breakdowns• when services are not available e.g radiotherapy, urology• when public services are inadequate – dialysis

– ICT system development and support – HMIS, THIS• Buying available private hospitals – Sabah and Sarawak

Private Financing Initiatives (PFI)– Research arrangements with industry

• Randomised Control Trials (RCTs) - CRC• Transgenic mosquitoes for Dengue control – IMR

– Development of new facilities – MOH RFPs• Private sector build & maintain - MOH rent first then transfer

ownership to government – Women and Child Hospital • Land swap – old MOH institutions on prized commercial land –

private sector build new complexes on private or MOH land – 1NIH research complex, Pharmacy complex

– Entry Point Projects (EPP) of NKEA Healthcare and ICT• Hospital Information System, Teleprimary Care and Oral Health

Information System for MOH facilities• Private health insurance for foreign workers• Training schools – John Hopkins with Perdana University

PRESENT – Private Sector Funds

Training of medical students/nurses/allied health • from private colleges in public facilities

Methadone programme • authorised GPs and later community pharmacists• govt provides methadone FOC• patients pay GPs consultation fees

Repeat medicine delivery via courier services • Pos Malaysia Sdn Bhd – RM5• patient’s choice and payment, CSR – 5% profits goes to

fund cancer drugs for those in need

PRESENT – Enhancing Service Delivery

Patient’s purchase of implants and prosthesis• Public providers facilitate – introduce patients to sales reps

for patient’s ease , having specific shops in hospitals• Extending financial support for eligible low-income

households to purchase artificial limbs and prosthetics. • Improve access to prosthetics by setting up at least one

prosthetics centre per state.

Locum arrangements • public doctors in private facilities

Contracting of private providers in public facilities• in PHC clinics and hospital on sessional basis• traditional and complementary care (TCM)

PRESENT – Enhancing Service Delivery

Current Challenges

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Overview of the MalaysianHealth System

12081

2199310

41249

143

38.4

802

10006

754378

11689

209

62.65

6371

0% 20% 40% 60% 80% 100%

Doctors (excl. Houseman)

Admissions

Hospital Beds

No. of Hospitals

Outpatient visits (m)

Health clinics (with doctors)

Series1 Series2

Public & Private Sector Resources and Workload (2008)

23Source: Health Informatics Center (HIC),MOH

11%

38%

41%

78%

74%

55%

PUBLIC PRIVATE

Challenges in Quantity and Severity

Manpower constraints(i) Absolute numbers

(ii) Mal-distribution - between public-private- within the public sector

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2009 doctor: population ratio - 1:1,255 (excluding houseman)New doctors registered with MMC1 - 1,4512 - 2,4133 - 3,172Target for Malaysia – 1:600

About 70% of patients managed by public sector specialists were complex cases compared with 25% of similar cases by

private sector specialists. Recently - backlash of Health Tourism

MOH primary health care providers treated more chronic illnesses compared to private GPs – treat the ‘healthy ill’(Source: PHC ACG study with Johns Hopkins, 2007)

THANK YOU

Dr Rozita Halina Tun Husseinrozitahalina@moh.gov.my