1CARE 1AIM: Evidence to Policy

Dato’ Dr. Maimunah Abdul HamidDeputy Director-General of Health

(Research & Technical Support)

Ministry of Health, Malaysia

5th National Conference for Clinical Research

(NCCR 2011)

23 June 2011

The Sunway Convention Centre, Selangor

1

Presentation Outline

• Translating policy directions into value-added 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

2

Translating Government Policy Directions into Value-

added Research for 1Care

3

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.

“AMANAT” YAB PM in 2005

“Gear up for less subsidy”, saysNajib. (Sunday Star, 6 March ‘05)

4

Evidence-based Policy-making for transformation

5

Discrepancy in Health Outcomes

by Geographical Location

6

Health Indicators :Prevalence by geographical location

%

Urban Rural

History of recent illness 22.4 25.5

Incidence of acute diarrhoea 4.7 5.5

Diabetes Mellitus 12.2 10.6

Hypertension 29.3 36.9

Smoking among adolescence 2.3 4.9

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

Public & Private Sector Resources and

Workload (2008)

7

Source: Health Informatics Center (HIC),MOH

13.54

12081

2199310

41249

143

38.4

802

16.68

10006

754378

11689

209

62.65

6371

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

Health Expenditure (RM billion) (2007)

Doctors (excl. Houseman)

Admissions

Hospital Beds

No. of Hospitals

Outpatient visits (m)

Health clinics (with doctors)

Public Private

10

11%

38%

41%

78%

74%

55%

45%

7

In absence of health financing reform, health system likely to become increasingly privatized…both in funding and service delivery……

In the future with no restructuring of the health system…..

Health expenditures per capita, 2009 prices

0

200

400

600

800

1000

1200

1400

1600

1800

2000

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

GGHE pc PvtHE pc

2004 2009 2018

GGHE 50% 45% 35%

PvtHE 50% 55% 65%

-PvtOOP 40% 47%

-PvtOther 15% 17%Source: Dr Christopher James, WHO WPRO – Projections from MNHA data8

1Care Concept

9

1Care Concept

1Care is the restructured integrated

health system that is responsiveand provides choice of quality

health care, ensuring universal coverage for the health care needs

of the population based on

solidarity and equity

1Care Concept

Receive

treatment

Home

Patient

PHCPPublic Private

Admit

ReferredHospital

(Public or

Private)

MOH Additional services

(Out of pocket or private health insurance)

Regional Health

Authority

PHCE PHCE

PHCE

MHDS

11

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

� 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

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

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

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

13 14

No Change and 1Care Reform:

Total Expenditure on Health (TEH)

2009 base year

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

1516

Gen Tax 44%

Socso&

EPF, 0.4%

OOP40%

PvtCorp & Others

7%

Gen Tax 35%

Socso & EPF, 0.0

0%

OOP 48%

PHI, 9%

PvtCorp

& Others

8%

Gen Tax Public Health &

others 17%

SHI

Gen Tax37%

SHI - Pvt

contribution 34%

Pvt. Spending

11%

Current system (2009)

No Change (2018)

1Care(2018)

PHI

7%

Financial Reforms

17

• 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

Focus Group Discussions with

Stakeholders - FINDINGS

Impact Analysis

A) Assessing impact on the Population

• Overall ability to pay

• Willingness to pay

• Un-insured population

• Informal sector

• Immigrant population

B) Assessing impact on the Economy

• Workforce mobility

• Labour market• Consumption

• Government Finance

• Cost of Institutional Change

• Private Health Insurance

18

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

Evidence to support the 1Care blueprint development

•Technical Working Groups (TWGs)

• Evidence & data

19

Blueprint Development : Technical

Working Groups (TWGs)

1. Primary Health Care

2. Secondary & Tertiary Care

3. Health Financing

4. Governance & Stewardship

5. Legislation, Regulation & Enforcement

6. Human Resource

7. ICT

8. Public Health

9. Oral Health

10. Pharmaceutical Services

Additional group – Strategic Communication 20

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

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

21

Evidence needs to ensure evidence-

based policies& tracking 1Care targets:monitoring & evaluation

22

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Targets of 1Care for 1Malaysia

• Universal coverage

• Integrated health care delivery system

• Affordable & sustainable health care

• Equitable (access & financing), efficient, higherquality care & better health outcomes

• Effective safety net

• Responsive health care system

• Client satisfaction

• Personalised care

• Reduce brain-drain

Sources of data

Resource

Inputs

Care

Processes

Service

Outputs

Patient or

organisation

level research

• Financing

• Manpower

• Facilities

• Drugs

• Devices

• Diagnosis

• Therapy

• Clinical services

• Procedures

• Out-patients

• In-patients

• Individual : clinical outcome

1. Intermediate (eg. BP control)

2. Ultimate (eg Mortality, QOL, Rehabilitation)

• Centre level performance

1. Effectiveness

2. Equity

3. Efficiency

4. Responsiveness

Population

level

research

• Disease burden incidence & prevalence

• Perception on healthcare system

• Utilisation on healthcare system (incl financial arrangement)

Healthcare System level

(public and private)

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 diseasesModified from Lim TO, 2007

Including M&E

Using Research Evidence to Improve

Health System Performance

– E.g. from NHS, UK

25

DR FOSTER INTELLIGENCE, Imperial College

Dr Foster Report Card Dr Foster Report Card

Developing Evidence-based Clinical

Practice Guideline

30

30

65

45

6266

7278

45

57

93

70

57

0

25

50

75

100

AU

S

CA

N

FR

GE

R

NE

TH

NZ

NO

R

SW

E

SW

IZ UK

US

Regional Comparative Analysis : Access to Doctor or Nurse When Sick or Needed Care

Percent*

14

33

17 16

5 5

28 25

28

19

AU

S

CA

N

FR

GE

R

NE

TH

NZ

NO

R

SW

E

SW

IZ UK

US

Same- or next-day appointment

Waited six days or more

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

* Base: Answered question.

31

33

20

34 33

5246

3329

44

26

34

0

25

50

75

AUS

CAN FR

GER

NETH N

Z

NO

RSW

E

SWIZ U

KUS

Percent

Regional Comparative Analysis :Wait Time in Emergency Room Before Being Treated

16

31

17

4 3

12 11

20

6 4

13

AUS

CAN FR

GER

NETH NZ

NO

RSW

E

SWIZ U

KUS

Less than 30 minutes Four hours or more

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

Base: Used ER in past two years.

Institutional strengthening for research

32

Why health research system needs to

transform?

• To contribute towards the achievement for Malaysia to be a high income nation

• To better support MOH’s new role in 1Care

• Breakdown walls to

– enhance function & roles of research institutions

– improve efficiency & reducing duplication of research activities

33

6 NIH (National Institutes of Health Research)

34

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

• Recognition

– Earn major awards

– Fellowships of prestigious academies & collages

35

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

36

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 technology37

our dream:1NIH

Centre for Information

Technology

(incl clinical support system)

Office of Communications and Public Liaison

Office of International Collaboration

Office of Research Ethics and Policy

Office of Program Coordination and Strategic

Initiatives

MOH Scientific Committee for

Medical Research

Office of the NIH Director

Office of Administrative

Management:

General Administration

Human Resource

Finance & Procurement

Facility Management

IMR

MOH

Centre for Biostatistics

Office of Research & Technical Services

Office of Research Management, Evaluation &

Technology Transfer & commercialization

CRCIHM IKU IHSR IHBR

Data Warehouse

Scientific Advisory Committee

38

our dream

The Proposed 1NIH must be BETTER than current model

• Strengths of current system will be preserved

• Stronger supportive role

• Separation of administrative & technicalfunctions

• Better integration of research activities

• More responsive to MOH needs & expectations through increased autonomy

39

our dream: 1NIH Complex Artist’s impression

40

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

• Better interventions

• Informing decision & policy making

• Internalisation by individuals -

changing behaviours &

empowering people

41

THANK YOU

Julio FrenkFormer Mexican

Minister of Health