1CARE 1AIM: Evidence to Policy

Dato Dr. Maimunah Abdul Hamid

Deputy Director-General of Health (Research & Technical Support) Ministry of Health, Malaysia

Presentation Outline

Translating policy directions into valueadded research Evidence-based policy-making for 1Care 1Care Concept Evidence to support the 1Care blueprint development Evidence needs to ensure evidence-based policies & tracking 1Care targets Institutional strengthening for research
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5th National Conference for Clinical Research (NCCR 2011)

23 June 2011 The Sunway Convention Centre, Selangor

AMANAT YAB PM in 2005

Malaysians must be prepared to. pay more . health and education a scheme .. quality service. On a review of the health care system, Najib and the Government was considering on a sustainable basis, amid increasing costs and demands. The question now is whether we can continue with the present situation or have some sort of scheme. Najib said adding that he would explain more about the health care system review soon.
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Translating Government Policy Directions into Valueadded Research for 1Care

Gear up for less subsidy, says Najib. (Sunday Star, 6 March 05)

Discrepancy in Health Outcomes by Geographical Location

Evidence-based Policymaking for transformation

Health Indicators : Prevalence by geographical location Urban

History of recent illness Incidence of acute diarrhoea Diabetes Mellitus Hypertension Smoking among adolescence
5

% Rural
25.5 5.5 10.6 36.9 4.9
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22.4 4.7 12.2 29.3 2.3

Source: National Health and Morbidity Survey (NHMS) III, 2006

Public & Private Sector Resources and Workload (2008)

11%

Health expenditures per capita, 2009 prices

2000 1800 1600 1400

Health clinics (with doctors) Outpatient visits (m)

802
38%

6371 38.4 62.65 209 11689 754378 10006 16.68

40% 60% 80% 100%
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1200 1000 800 600

In the future with no restructuring of the health system.. In absence of health financing reform, health system likely to become increasingly privatized both in funding and service delivery
2018 35% 65%
47% 17%
Source: Dr Christopher James, WHO 8 WPRO Projections from MNHA data

41%

No. of Hospitals
78%

143 41249
74%

400 200 0

Hospital Beds Admissions

55%

2199310 12081
45%

Doctors (excl. Houseman) Health Expenditure (RM billion) (2007) Public Private 0%

13.54
20%

GGHE PvtHE
-PvtOOP -PvtOther

Source: Health Informatics Center (HIC),MOH 7 7

1Care Concept

1Care Concept

Streamlined MOH focused on governance, stewardship & specific public health services, training & research
MOH MHDS

Patient

Additional services (Out of pocket or private health insurance)

Regional Health Authority

PHCP
Public Private

Referred Admit

Hospital (Public or Private)

Autonomous Malaysian Healthcare Delivery System (MHDS)- integrated public & private sector providers. Emphasis on primary health care. Gatekeeper to higher levels of care Publicly managed health fund - combination of general government revenue & social health insurance (SHI), & may be tempered by minimal co-payments at point of seeking care Single payer system, the National Health Financing Authority (NHFA) set-up on a not-for-profit basis under the MOH Government commits to higher levels of spending for healthcare
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Receive treatment
PHCE PHCE PHCE

Home

People commit to increased cost sharing through pooling of funds and cross-subsidy 12

20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19
GGHE pc PvtHE pc

2004 50% 50%

2009 45% 55%

40% 15%

1Care Concept

1Care is the restructured integrated health system that is responsive and provides choice of quality health care, ensuring universal coverage for the health care needs of the population based on solidarity and equity

Features of 1Care

Presentations to YAB PM & Economic Council

11 August 2009 - 1Care for 1Malaysia concept Follow-up - 22 March 2010, MOH presented research information requested by the Prime Minister and EC: i. Financial projection of health spending
- in collaboration with Dr Christopher James, Health Economist, WHO - projections by Bank Negara Malaysia for comparison

No Change and 1Care Reform: Total Expenditure on Health (TEH)

ii.

Focus Group Discussion with various stakeholders

iii. Impact Assessment

- in collaboration with Prof Soonman Kwon, Seoul National University - local consultant - Chang Yii Tan, PE research
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2009 base year

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Summary of Financial Projections

1. No Change Health system likely to be increasingly dichotomous Private health expenditure will rise faster than public expenditure Private spending is mainly from out-of-pocket payment greater inequity & financial risk to the people and further erosion of the public health system 2. 1Care Reform Can contain growth of total health expenditure based on public sector management and prudency Savings are more in private spending Shortfall in SHI contribution due to health expenditure growing faster than wages Government portion of health expenditure will be higher

Financial Reforms
Current system
(2009)
PHI 7%
Pvt Corp & Others 7% Gen Tax 44% OOP40 % Socso & EPF, 0.4%

PHI, 9%

No Change
(2018)

Pvt Corp & Others 8%

Gen Tax 35%

OOP 48%
Socso & EPF, 0.0 0%

Pvt. Spending 11%

Gen Tax Public Health & others 17%

1Care
(2018)
SHI - Pvt contribution 34% SHI Gen Tax 37%
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Focus Group Discussions with Stakeholders - FINDINGS

General consensus among funders, users & providers - concept and proposal was favorable Most stakeholders were in favour of the delivery concept Funders & users were concerned about having to pay
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Impact Analysis
A) Assessing impact on the Population
Overall ability to pay Willingness to pay Un-insured population Informal sector Immigrant population

C) Assessing impact on the Health System

Health Care Utilisation Quality of Care and Health Outcomes Health Care Cost Equity in Access to Health Services Impact on Providers Impact on Medical Tourism

B) Assessing impact on the Economy

Workforce mobility Labour market Consumption Government Finance Cost of Institutional Change Private Health Insurance

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Blueprint Development : Technical Working Groups (TWGs)

1.

Primary Health Care Secondary & Tertiary Care Health Financing Governance & Stewardship Legislation, Regulation & Enforcement Human Resource ICT Public Health Oral Health

Evidence to support the 1Care blueprint development

Technical Working Groups (TWGs) Evidence & data

2. 3. 4. 5. 6. 7. 8. 9.

10. Pharmaceutical Services

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Additional group Strategic Communication

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On-going research to support blueprint development

7 research areas identified since 2008 only 1 pending, 1 done 1. Health Facility & Services Survey & Population profiling:
Mapping health facilities & services against health care needs for strategic policy development

2. Health Care Demand Analysis: Utilisation & equity analysis, models & policy
simulation for 1Care

Evidence needs to ensure evidencebased policies & tracking 1Care targets: monitoring & evaluation

3. Cost Analysis: unit costing for out-patient & ambulatory services in public hospitals 4. Analysis of Financial Arrangements & Expenditures: in public
& private sectors

5. Community Perception: on health care delivery systems

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Targets of 1Care for 1Malaysia

Universal coverage Integrated health care delivery system Affordable & sustainable health care Equitable (access & financing), efficient, higher quality care & better health outcomes Effective safety net Responsive health care system Client satisfaction Personalised care Reduce brain-drain
23 Population level research
Disease burden incidence & prevalence Perception on healthcare system Utilisation on healthcare system (incl financial arrangement)

Sources of data
Healthcare System level
(public and private) Including M&E

Patient or organisation level research

Individual : clinical outcome 1. Intermediate (eg. BP control) 2. Ultimate (eg Mortality, QOL, Rehabilitation)

Resource Inputs
Financing Manpower Facilities Drugs Devices

Care Processes
Diagnosis Therapy Clinical services Procedures

Service Outputs
Out-patients In-patients

Centre level performance

1. Effectiveness 2. Equity 3. Efficiency 4. Responsiveness

Where are the data? NHMS= National Health Morbidity Surveys; BOD = burden of disease report; MNHA=Malaysian National Health Account; PR =Patient registries; HSI =Healthcare statistics initiatives (Drugs, Device/Med. Technology, Healthcare Workforce & Facilities surveys); HRMIS= Human Resource Management Information System, HIC =Health Informatics Center , CD =Communicable disease, NCD =Non communicable diseases Modified from Lim TO, 2007

DR FOSTER INTELLIGENCE, Imperial College

Using Research Evidence to Improve Health System Performance E.g. from NHS, UK

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Dr Foster Report Card

Dr Foster Report Card

Developing Evidence-based Clinical Practice Guideline

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Regional Comparative Analysis :

Access to Doctor or Nurse When Sick or Needed Care
Percent*

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Same- or next-day appointment

93 72 78 70 57 45
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Waited six days or more

75 65 50

62 45

66

57

28 25 17 16 5 5
NZ NO R SW E

25

14

19 2 8
UK US

0
NZ NE TH NO R GE R CA N FR UK
NE TH

SW IZ

SW E

GE R

CA N

AU S

US

AU S

FR

* Base: Answered question. Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries. 30

SW IZ

Regional Comparative Analysis :

Wait Time in Emergency Room Before Being Treated
Less than 30 minutes
Percent

Four hours or more

75

52
50

46 33 34 33 20 33 29

44 34 26 16 17 4 3
TH NZ R W E N O

Institutional strengthening for research

31 20 12 11 13 6 4
UK US

25

0
G E R N E TH N Z N R FR S IZ
N S R NE

Base: Used ER in past two years.

SW IZ

UK

W E

US

FR

N O

SW

G E

AU

CA

AU

C A

Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.

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Why health research system needs to transform?

To contribute towards the achievement for Malaysia to be a high income nation To better support MOHs new role in 1Care Breakdown walls to enhance function & roles of research institutions improve efficiency & reducing duplication of research activities

6 NIH (National Institutes of Health Research)

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Research Excellence - the Vision

Leaders in niche research areas Tract record in publications Opinion leaders Attract external funding Attract internal collaboration Improvements in policy & practice
patients care patients outcome

What shall we do?

1. Improving governance Strengthening research governance 2. Improving capacity & capability of human resource Leadership Attracting & retaining quality researchers Defined career structure (entry as trainee, researcher & senior researcher) 3. Realigning & consolidating current roles More focused Avoid duplication & improve efficiency Better synergy
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Recognition Earn major awards Fellowships of prestigious academies & collages

What shall we do?

4. Optimising the use of scarce research expertise & other resources Sharing of physical & human resources 5. Improving funding Generating funds 6. Adopting newer roles Broker (searching for external funds & outsourcing of research) Marketing of services & products 7. Application of advance technology
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our dream:
MOH Scientific Committee for Medical Research Scientific Advisory Committee
Office of Administrative Management:
General Administration Human Resource Finance & Procurement Facility Management

1NIH
Office of Research Ethics and Policy Office of Program Coordination and Strategic Initiatives Office of Research Management, Evaluation & Technology Transfer & commercialization Office of Communications and Public Liaison

MOH

Office of the NIH Director

Office of International Collaboration Office of Research & Technical Services

IHM

CRC

IMR

IKU

IHSR

IHBR

Centre for Information Technology

(incl clinical support system)

Data Warehouse

Centre for Biostatistics

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our dream The Proposed 1NIH must be BETTER than current model
Strengths of current system will be preserved Stronger supportive role Separation of administrative & technical functions Better integration of research activities More responsive to MOH needs & expectations through increased autonomy

our dream: 1NIH Complex

Artists impression

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our AIM: Evidence to Policy & Practice WE CAN make better contribution to health

Julio Frenk
Former Mexican Minister of Health

Better interventions Informing decision & policy making Internalisation by individuals changing behaviours & empowering people

THANK YOU

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