Reforms in Health System Potential Impact On Public Health and Public Health Practitioners

DEPARTMENT OF PUBLIC HEALTH AND COMMUNITY MEDICINE
INTERNATIONAL MEDICAL UNIVERSITY
Reforms in Health System: Potential Impact

on Public Health and Public Health
Practitioners
Professor Emeritus Dato’ Dr Syed Mohamed Aljunid

MD (UKM) MPH ( Singapore) PhD (London); DLSHTM (London); FAMM, FPHMM, FASc
Professor of Health Economics, Policy and Management
Senior Consultant in Public Health Medicine
Department of Public Health and Community Medicine
School of Medicine
International Medical University
Copyright of Syed Aljunid©️
Founder and Advisor

International Centre for Casemix and Clinical Coding
Universiti Kebangsaan Malaysia
Outline
◆What is Health Reform and Health Sector Reform?
◆Three Main Reasons for Reform
◆Why Need Health Reform?
◆What Triggers Health Sector Reform?
◆Reforms in Other Countries
◆Why Health Reform is Needed in Malaysia ?
◆Health White Paper: The Reform
◆Impact on Public Health Practitioners
◆Conclusion
Copyright of Syed Aljunid
What is Health Sector Reform?
◆Sustained process of fundamental change in policies and

institutional arrangements of the health sector
▪ WHO (SEARO), 1977
◆Sustained, purposeful change to achieve efficiency, equity
and effectiveness of the health sector
▪ Cassel A, 1995
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What is Health System Reform?

❖ Health Sector Reform
◼ Defining Policies
◼ Refining Existing Policies
◼ Reform Institutions which carry out policies
➢ System
➢ Service Delivery
➢ Financing
➢ Institutional
❖ Health Care Reform
◼ Broader reform
◼ Not confine to Health Sector
◼ Other Social Sector involved
Source: Senkubuge et al (2014) Glob Health Action 7: 2356

http://dx.doi.org/10.3402/gha.v7.23568
Main Reasons for Health System

Reform
Inadequate Access to
Health Care
Inefficient Use of
Scarce Resources
Service Unresponsive
to Needs of People
Copyright of SyedAljunid©️
Why Need Health System Reform?

◆Inadequate Access to Health Care
▪ Poverty
▪ Geographical location
• Urban vs Rural
▪ Age and Sex
▪ Employment status
▪ Unavailability of essential services
• Infections : STDs
• Chronic Diseases: Diabetes, HT, IHD
▪ Poor planning and Management of Service
• Unutilised Facilities
Why Need Health Care Reform?

◆Inefficient use of scarce resources
▪ Funds spent on inappropriate and cost-
ineffective services
▪ Priority to Tertiary care rather than primary
care
▪ Too much emphasis Curative rather than
preventive and promotive services
▪ Poor monitoring on how resources being spent
▪ System of purchasing goods and services not
ensuring value for money
Why Need Health Care Reform?

◆Services not responsive to need of people
▪ Poor quality of services
• Public Sector
– Long waiting time
– Unmotivated staff
– Incovinient clinic hours
– Inadequate supplies of drugs
– Lack of privacy and confidentiality
• Private Sector
– Financial Exploitation
– Dangerous treatment and procedures
– Poorly Trained Support Staff
What Triggers Health Sector Reform?
◆Influence of Major Donors

◆Reform in Public/Civil Service
◆Development in Economics of Health and Epidemiology
◆Major challenges in health system (e.g Covid-19 Pandemic)
◆Change in the government
Health Reforms in Other Countries:

Indonesia
12 DEPARTMENT OF PUBLIC HEALTH AND COMMUNITY MEDICINE
JAMINAN KESEHATAN
KEMENKES
NASIONAL Indonesia
Pemerintah
BPJS
Kendali Biaya & kualitas Yankes

Kesehatan Regulasi Sistem Pelayanan
Kesehatan (rujukan, dll)
Regulasi (standarisasi)
Kualitas Yankes, Nakes,
Regulato Obat, Alkes
r
Regulasi Tarif Pelayanan
Kesehatan,
Pembayar tunggal, regulasi, kesetaraan
Peserta Memberi Pelayanan

Fasilitas
Jaminan Kes Mencari Pelayanan Kesehatan
Sistem Rujukan
JAMINAN
KESEHATAN
NASIONAL
Vietnam
◆Background
▪ Population: 97 million GDP Per Capita: USD 2,785
▪ OOP Expenditure is the main source of health funding
▪ Social Health Insurance has been developed and implement since 1992
◆Health System Reform
▪ Introduction of Compulsory Health Insurance (HCFP) to cover all poor
households and disadvantaged groups
▪ Eligible Population: The poor, socially protected groups, elderly and war
dioxin victims
Vietnam
◆Source of Funding for HCFP: ◆Outcome
▪ 100% public funding ▪ 15 million people covered in 2009
• Central Government: USD 2.50 per ▪ Positive impact in reducing OOP
expenditure
year beneficiary per year
• Provincial Government: USD 0.84 ▪ No impact on health utilisation
per beneficiary per year ▪ Fee-For Service reimbursement leading
▪ Benefits: to over-treatment by physicians and

supply-induced-demand
• Outpatient, Inpatient Care, ▪ Proposal to change provider payment to
Laboratory and X-rays Capitation and Casemix
▪ Administration of HCFP taken over by
Vietnam Social Security that managed all
Social Insurance in Vietnam from 2003
The Philippines
◆Background ◆ Philippines Health Insurance
▪ Population size: 109 million (2020) Corporation (PhilHealth)
▪ Size: 300,000 sq km ▪ Established in 1995
▪ Percapita GDP:USD 3,298 ▪ Government-owned organisation
▪ GDP Growth: -3.51% (2020) ▪ Claimed to have achieved UHC by 2013
▪ THE: 4.7% of GDP with 86% coverage
▪ Percapita Expenditure on Health: USD 137 (2018) ▪ Benefit package:
• Out-patients
• In-patient (Maximum 45 days/year)
• Deliveries
• Surgical Procedures
• Catastrophic Conditions
Mexico
◆Background
▪ Population: 129 million; per capita GDP: USD 8,346
▪ WHO Report in 2000 highlights that more than half of the population faced with
catastrophic health expenditure
▪ Main problem is social inequity in the population
◆Health System Reform

▪ Introduce System of Social Protection in Health (SSPH)
▪ Seguro Popular (SP)
• Innovation in the reform to provide financial protection to those not covered by other schemes
• Anyone not covered by Social Security is eligible to enroll
• Voluntary Health Insurance with free access to wide range of health services
Mexico
◆Seguro Popular (SP) ◆Outcome
▪ Source of Funding ▪ 15 years trend study
• Federal Government • Improved access to health services
and drugs
• State Government • Reduction in Out-Of-Pocket
• Families ( through premium) Expenditure the poor
▪ In 2005: USD 1 billion invested in SP • Reduction in Incidence of
• 75% by Federal and 25% by State Government Catastrophic Expenditure
• Most families do not pay for the Premiums
▪ In 2006: 266 health interventions and 312 type Copyright of SyedAljunid©
of drugs covered by SP free of charge
Why Reform is Needed in Malaysia?
◆Increasing Prevalence of Non-Communicable Diseases

◆Aged Population
◆Fragmented Health System
◆Inadequate Funding for Optimum Function
◆MOH Diverse Roles in Health System
Increasing Prevalence of Non-

Communicable Diseases
◆Increasing Prevalence of Non-Communicable Diseases
▪ Diabetes Mellitus
▪ Hypertension
▪ Cancers
▪ Ischemic Heart Disease
Diabetes Mellitus
Overall Prevalence DM:

2011: 11.2%
2015: 13.4%
2019: 18.3 %
Hypertension
Overall Prevalence DM:

2011: 32.6%
2015: %
2019: 30.0%
Economic Burden of NCDs
Three Selected NCDs:

Cardiovascular Diseases
Diabetes Mellitus
Cancers
Aged Population
Number of older persons by age group (in year 2010, 2020, 2030 & 2040
Age Group YEAR
2010 2020 2030 2040
Number of Older Persons
Age of 60 and over 1,361,500 2,098,000 2,805,900 3,341,000
Age of 70 and over 642,700 947,800 1,485,700 2,002,100
Age of 80 and over 244,400 395,100 604,500 952,200
Total 2,248,600 3,440,900 4,896,100 6,295,300
Proportion of Older Person by Age (%)
60-69 60.55 60.97 57.30 53.07
70-79 28.58 27.55 30.34 31.80
80 and over 10.87 11.48 12.36 15.13
Total 100.0 100.0 100.0 100.0
(Data Source: Population Projection in Malaysia, DOSM 2010-2040) Copyright of SyedAljunid©

Aged Population
Number and percentage of older persons in Malaysia (60 years or over)
by sex, 1970 -2020
4500
10.6
10.0
4000
Proportion of Older Persons to Total Population (%)

Female Male %
3500
7.8
8.0
Number of Older Persons ('000)
3000
6.2
2500 51.3%
5.7 6.0
5.5
5.2
2000
50.9% 4.0
1500
1,068.5
52.3%
1000
52.7% 48.6% 2.0
500 50.6% 49.1%

47.8%
47.7%
47.3%
52.2% 49.4%
0 0.0
1970 1980 1990 2000 2010 2020
(Source: Department of Statistics Malaysia 2017 Copyright of SyedAljunid©
Year
Malaysian Health System:

Dichotomy
PUBLIC PRIVATE
SECTOR SECTOR
• Ministry of •Private
Health Hospitals
• Ministry of •Private Clinics
Education •Pharmacies
• Ministry of •Laboratories
Defense •Hospice
• Local •Nursing Homes
Authorities
•NGOS
Total Health Expenditure As %

of GDP (2020)
18 16.77
16
14 12.49 12.53
12 10.15 9.83
10
8 6.99
4.3 5.84
5.25
6
2.9 4.08 4.88
3.79 2.6 3.76
4 2.16
2
0
Health Spending (OECD)

CURRENT HEALTH EXPENDITURE

(% OF GDP_
Source of Funding
◆ OOP on Health is high.
◆ In 2020, OOP was 34.5% of THE
◆ WHO proposes OOP to be <
20%
▪ For Equity and Financial
Protection
◆ Other Countries
▪ Thailand = 8.67%
▪ Japan = 12.9%
▪ Turkiye = 16.9%
▪ Australia = 15.9%
▪ UK= 17.1%
▪ France=9.26%
OOP Expenditure as % of THE

(2019)
50
45 43.21
40
35.15
35 32.57 32.17
30
25
20 18.01
15 13.63 13.86
10
0
Malaysia Low Income Muddle Income Upper Middle Income High Income OECD World
Copyright of ITCC-UKM
Reform of Health System:

Health White Paper
◆Four Pillars of HWP
▪ Transforming Healthcare Service
Delivery
▪ Advancing Health Promotion and
Prevention
▪ Ensuring sustainable and
equitable health financing
▪ Strengthening health system
foundation and governance
Pillar 1
◆Transforming Healthcare Service Delivery

▪ Prioritizing Primary Health Care
▪ Optimizing Hospital Care Services
▪ Increasing Effective Public-Private Partnership
▪ Harnessing Digital Technology
▪ Ensuring equity in healthcare delivery
Pillar 1
Pillar 1: Impact of Public Health

Practitioners
◆Be prepared to enhance your role as District Health
Officers
◆Equip yourself with skills to manage health facilities
including hospitals
◆Learn to manage public-private interactions and networking
◆Be prepared to work with private providers
◆Be familiar with transformation in digital health
◆Learn how to manage autonomous hospitals
Pillar 2
◆Advancing Health Promotion and Prevention

▪ Strengthening Public Health Functions
▪ Improving Intersectoral coordination and collaboration for Health
▪ Incentivizing pro-health practices and behaviours
Pillar 2
Pillar 2: Impact on Public Health

Practitioners
◆Learn new skills to manage health promotion
◆Be familiar on incentives schemes for providers on health
promotion
◆Be ready to enhance intersectoral collaboration
◆Learn to manage population incentives for health
prevention
Pillar 3
◆Ensuring sustainable and equitable health financing

▪ Increasing investments for health
▪ Ensuring population receive affordable comprehensive health
services
▪ Ensuring effective and efficient health spending

Practitioners
◆Enhance skills in health economics and financing
◆Learn how to manage Strategic Purchasing and Provider
Payment Methods
◆Learn how to manage and control moral hazards
◆Obtain skills on financial evaluation and monitoring
◆Learn how to measure efficiency and equity
Pillar 4
◆Strengthening health system foundation and governance

▪ Restructuring of MOH Roles
▪ Strengthening policies, legislation and regulations
▪ Fortifying the health workforce
▪ Stimulating research, innovation and evidence-based policy
making
Current Roles of MOH
Policy
Maker
R&D Funder
MOH
Education
& Regulator
Training
Provider
Potential Future Roles of
MOH
Policy
Maker
MOH
Provider Regulator


Practitioners
◆Learn effective policy making process
◆Enhance skills in policy analysis and decision making
◆Be prepared to move to “real” public health practice
◆Learn how to be innovative in public health practice
New Skills for Public Health

Practitioners
◆Health Management and Leadership
▪ Leadership and Communication Skills
▪ Conflict Resolutions
▪ Health Planning and Evaluation
▪ Health Human Resource Management
New Skills for Public Health

Practitioners
◆Health Economics and Financing
▪ Social Health Insurance & Other Financing Mechanisms
▪ ICD-11 and Procedure Classifications
▪ Casemix System
▪ Management of Big Health Data
▪ Costing Methods and Tariff Development
▪ Economic Evaluation (CEA/CMA/CBA/CUA)
The Right Attitudes for Reform
◆Embrace Health Reform Fully

◆Be part of the Solutions (not the problems)
◆Work with Others
◆Learn from Experts
◆Adopt Continuous Learning Practice
Why Reforms Failed?

◆Lack of Political Will to pursue the reform
◆Weakness of Reform Team
▪ Technical Capacity of Staff/Silos)
◆Lack of Information (Cost/PPM etc)
◆Fighting over control of the proposed Agency
◆Roles of potential losers: Private Insurers
◆Lack of Transparency and Public Consultation
◆Loss of public confidence on government to handle
large fund (Cronyism, Corruptions)
Health Financing Issues in SEA: Challenges in

Achieving UHC. Lancet (2011), 377 : 863-73
CONCLUSION
◆Health Reform is the response towards internal and external pressure
on health system
◆Social, Financial and Service Factors are among the triggers for
Health Reform
◆Four pillars in Health White Paper focused on Service Delivery,
Health Promotion, Health Financing and Future roles of MOH
◆Health Prevention and Health Financing will dominate the Health
Reform
◆Public Health Practitioners should be ready to equipped themselves
with new skills and knowledge to embrace health reform Copyright of SyedAljunid©
Thank You
syedmohamed@imu.edu.my
saljunid@gmail.com

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DEPARTMENT OF PUBLIC HEALTH AND COMMUNITY MEDICINE

INTERNATIONAL MEDICAL UNIVERSITY

Reforms in Health System: Potential Impact

Professor Emeritus Dato’ Dr Syed Mohamed Aljunid

Founder and Advisor

What is Health Sector Reform?

◆Sustained process of fundamental change in policies and

What is Health System Reform?

Source: Senkubuge et al (2014) Glob Health Action 7: 2356

Main Reasons for Health System

Why Need Health System Reform?

Why Need Health Care Reform?

Why Need Health Care Reform?

What Triggers Health Sector Reform?

◆Influence of Major Donors

Health Reforms in Other Countries:

Kendali Biaya & kualitas Yankes

Peserta Memberi Pelayanan

▪ Benefits: to over-treatment by physicians and

◆Health System Reform

Why Reform is Needed in Malaysia?

◆Increasing Prevalence of Non-Communicable Diseases

Increasing Prevalence of Non-

Overall Prevalence DM:

Overall Prevalence DM:

Economic Burden of NCDs

Three Selected NCDs:

(Data Source: Population Projection in Malaysia, DOSM 2010-2040) Copyright of SyedAljunid©

Proportion of Older Persons to Total Population (%)

500 50.6% 49.1%

Malaysian Health System:

Total Health Expenditure As %

Health Spending (OECD)

CURRENT HEALTH EXPENDITURE

OOP Expenditure as % of THE

Reform of Health System:

◆Transforming Healthcare Service Delivery

Pillar 1: Impact of Public Health

◆Advancing Health Promotion and Prevention

Pillar 2: Impact on Public Health

◆Ensuring sustainable and equitable health financing

Pillar 3: Impact on Public Health

◆Strengthening health system foundation and governance

Copyright of Syed Aljunid

Pillar 4: Impact on Public Health

New Skills for Public Health

New Skills for Public Health

The Right Attitudes for Reform

◆Embrace Health Reform Fully

Why Reforms Failed?

Health Financing Issues in SEA: Challenges in

Copyright of Syed Aljunid

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