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Public–Private Partnerships in Health in Malaysia:

Lessons for Policy Implementation
a b c
Kai-Lit Phua , Sharon Wan-Hui Ling & Kai-Hong Phua
a
School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway,
Malaysia
b
Monash University Malaysia, Bandar Sunway, Malaysia
c
Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore,
Singapore
Published online: 01 Jul 2014.

To cite this article: Kai-Lit Phua, Sharon Wan-Hui Ling & Kai-Hong Phua (2014) Public–Private Partnerships in Health
in Malaysia: Lessons for Policy Implementation, International Journal of Public Administration, 37:8, 506-513, DOI:
10.1080/01900692.2013.865647

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 International Journal of Public Administration, 37: 506–513, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 0190-0692 print / 1532-4265 online
DOI: 10.1080/01900692.2013.865647

Public–Private Partnerships in Health in Malaysia: Lessons for Policy

Implementation
Kai-Lit Phua
School of Medicine and Health Sciences, Monash University Malaysia, Bandar Sunway, Malaysia

Sharon Wan-Hui Ling

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Monash University Malaysia, Bandar Sunway, Malaysia

Kai-Hong Phua
Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore, Singapore

The government of Malaysia, an early and enthusiastic supporter of the concept of privatization
of public services, can also be considered as being highly supportive of more recent strategies
such as “public–private partnerships” (PPPs) in the delivery of social services. It established
a Public–Private Partnership Unit (UKAS) in 2011. This discussion of Malaysia’s experience
with health care PPPs is based on a literature review. The record is mixed, with successes
and failures. Critical factors for success include regulation, transparency, clear policy guid-
ance and clarity on operational procedures and responsibilities, proper evaluation mechanisms,
sustained financial support, especially for NGO partners, and unwavering commitment from
policy-makers.

Keywords: public–private partnerships, health care, Malaysia

INTRODUCTION
The government of Malaysia, an early and enthusiastic sup-
porter of the concept of privatization of public services
(Jomo, 1995), can also be considered as being highly sup-
portive of more recent developments such as “public–private
partnerships” (PPPs) in the delivery of social services. High-
level support for the latter is indicated by the establishment
of a Public–Private Partnership Unit (UKAS) in the Prime
Minister’s Department in 2011.
Because of Malaysia’s long experiment with privatization
and the subsequent adoption of the concept of PPP (together
with the strategy of utilizing private sector resources in the
delivery of social services such as health care), its experience
could provide valuable lessons for other nations. This arti-
cle aims to look at specific Malaysian PPP “successes” and
Correspondence should be addressed to Kai-Lit Phua, School of
Medicine and Health Sciences, Monash University Malaysia, Jalan Lagoon
Selatan, Bandar Sunway, 46150 Malaysia. E-mail: phuakl@hotmail.com
“failures” in the area of health care, and the factors leading
to these results.
The term “public–private partnership” has been defined
in various ways. For example, the broad definition used
by Hodge and Greve (2009) is “cooperative institutional
arrangements between public and private sector actors”
(p. 33). They noted that the term PPP seems to encom-
pass five types of arrangements, that is, joint production
and risk sharing; long term infrastructure contracts; public
policy networks; civil society and community development
projects; and urban renewal and downtown development
projects (Hodge & Greve, 2007).
Michael Reich (2002) defines a PPP as involving “at least
one private for-profit organization and at least one not-for-
profit or public organization . . . the partners have some
shared objectives for the creation of social value, often for
disadvantaged populations . . . (and) the core partners agree
to share both efforts and benefits” (p. 3).
The Organisation for Economic Co-operation and
Development (OECD) explicitly excludes nonprofit organi-
zations from its definition of PPP. According to the OECD
 PUBLIC–PRIVATE PARTNERSHIPS IN HEALTH IN MALAYSIA
(n.d.), a PPP is an arrangement for “delivering and fund-
ing public services using a capital asset where project risks
are shared between the public and private sector. . . . (and
it is) . . . a long term agreement between the government
and a private partner where the service delivery objectives
of the government are aligned with the profit objectives of
the private partner” (p. 3).
The World Bank Institute (2012) states that a PPP
is essentially an arrangement to “mobilize private sector
resources—technical, managerial, and financial—to deliver
essential public services such as infrastructure, health
and education” (“Overviews”), while the World Health
Organization (WHO) views it as a means to “bring together a
set of actors for the common goal of improving the health of
populations based on mutually agreed roles and principles”
(Kickbusch & Quick, 1998, p. 69). In terms of such partner-
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ships in the area of health services, Malaysia’s Ministry of
Health (MOH) does not use the term “public–private partner-
ship”; instead, it uses the term “public–private integration” to
signify cooperation between the public and private sectors,
and the utilization of private sector resources to bring about
more equitable delivery of services.
PPP PERFORMANCE AND FACTORS
AFFECTING PERFORMANCE
The evaluation of “success” and “failure” in PPP perfor-
mance can be carried out along different dimensions, for
example, financial (such as value-for-money), equity, access,
quality, and so forth. There is the possibility that some of
these dimensions may clash; for example, the promotion
of access may increase costs, and greater equity in service
delivery may affect overall quality.
PPP success or failure may depend on factors indepen-
dent of the soundness of the design of the PPP itself. For
example, Ismail and Ajija’s survey study (2011) of perceived
critical success factors (CSFs) for successful PPP projects
in Malaysia reveals that the top five perceived CSFs in
descending order appear to be (1) good governance; (2) com-
mitment and responsibility of public and private sectors;
(3) favorable legal framework; (4) sound economic policy;
and (5) available financial market. In the authors’ survey of
179 public and private sector respondents, rankings provided
by the former were found to differ slightly from the lat-
ter, as public sector respondents perceived the top five most
important CSFs to be (1) good governance; (2) commitment
and responsibility of public and private sectors; (3) project
technical feasibility; (4) transparent procurement process;
and (5) favorable legal framework. On the other hand, pri-
vate sector respondents perceived the top five most important
CSFs to be (1) good governance; (2) available financial mar-
ket; (3) favorable legal framework; (4) commitment and
responsibility of public and private sectors; and (5) sound
economic policy. The two factors ranked as least important
507
for PPP success were government involvement by providing
guarantee and political support. The authors further elabo-
rated on the importance of each factor—namely that good
governance is necessary to avoid PPP failure, that com-
mitment is essential to ensure that PPP goals are attained,
that favorable legal frameworks are needed to prevent cor-
ruption, that sound economic policy and a stable economic
environment will reduce risk and allow private sector part-
ners to operate with confidence, and that easy access to
financial markets—through the availability of flexible and
attractive financial instruments such as debt, equity, supplier
and purchaser credit, and securities—is important to enable
private financing of PPP projects. The authors observed that
at the time of the study, no specific legal framework for PPP
projects in Malaysia was in existence. Moreover, the authors
were worried by the fact that respondents ranked “appro-
priate risk allocation and risk sharing” as a lower concern
for PPPs. They argued that authorities should emphasize the
importance of risk and reasonable risk-sharing in order to
maximize value-for-money achieved from PPPs.
Sundaram and Chowdhury (2009) caution that PPPs in
developing countries may not yield anticipated results as
governments often lack the institutional and human resource
capacity to handle the complexities of PPPs, especially
where financial contracts are concerned. As such, PPPs can
suffer from corruption, cronyism, and monopolies. Transfer
of risk to private contractors may be partial, and govern-
ments may have to step in if something goes wrong. While
PPP contracts may initially appear to relieve governments of
heavy investment expenditures and seem to improve fiscal
balances, government commitments to pay for future service
flows and other contingent liabilities pose economic effects
that are similar to public debt accumulation. Thus PPPs may
not necessarily entail lower capital costs in the long run.
METHODS
A literature review search was conducted to determine the
type, extent, and content of information on health sector
PPPs in Malaysia and on factors leading to success or failure
for these arrangements.
Searches using keywords such as “Malaysia AND health
AND public–private partnerships”, “Malaysia AND health
AND public–private integration”, and “Malaysia AND
health AND partnerships” were conducted using online
international databases such as PubMed, Medline, and
Global Social Policy. Searches were also conducted on
online repositories of major Malaysian universities such as
Universiti Malaya (UM), Universiti Sains Malaysia (USM),
Universiti Kebangsaan Malaysia (UKM), Universiti Putra
Malaysia (UPM), UTM (Universiti Teknologi Malaysia),
and IIUM (International Islamic University Malaysia).
The methodological framework for selection of articles
was that the studies of Malaysian PPPs must contain rigorous
 508 PHUA, LING, AND PHUA
analysis of institutional strengths or weaknesses, and they
must also discuss factors that affected “success” or “failure”,
as opposed to studies that are purely descriptive in nature.
Case studies unearthed and selected for inclusion include the
following:
privatization of drug procurement,
outsourcing of hospital support services,
public–private sector dialysis provision,
harm reduction programs involving NGOs and private
providers,
domestic violence support collaborations between the
MOH, public hospitals, and women’s NGOs,
medical tourism, and
medical education.
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Although data from MOH annual reports confirm the exis-
tence of other initiatives between public and private hospitals
or public and private sector medical personnel, the absence
of independent reports or assessments of outcomes and fac-
tors exclude these PPPs from this review. Of further note
is that although some scholars (Sundaram & Chowdhury,
2009) view PPPs as separate from privatization, this litera-
ture review considers outsourcing of services as a PPP given
its inclusion in the MOH’s definition of “public–private
integration” initiatives.
PPPs IN HEALTH IN MALAYSIA
From the perspective of the MOH, public–private integration
initiatives are often meant to fulfill one or more of these
health policy objectives: to increase access, promote equity,
reduce operational costs, reduce the burden of government
in service provision, or correct imbalances between public
and private sectors such as in the area of staff and resource
availability. Our survey of the literature suggests that
health care PPPs in Malaysia have a mixed track record in
achieving these objectives. This literature review focuses
on several case studies of health sector PPPs in Malaysia,
highlights associated institutional strengths and weaknesses,
and identifies factors contributing to the successes or failures
of those PPPs.
Ghani’s discussion (2006) of PPPs in Malaysia include
the engagement of private sector specialist doctors to provide
sessional services in public sector teaching hospitals, the pur-
chase of services from the private sector (i.e., CT scans,
radiotherapy, hemodialysis, and PAP smears), and the pri-
vatization or contracting-out of hospital services (e.g., linen
and laundry and clinical waste disposal), and even training
(i.e., private nurses in public training schools).
More recently, the MOH’s Country Health Plan: 10th
Malaysia Plan 2011–2015 (2010) lists several exam-
ples of public–private integration initiatives: namely, the
outsourcing of medical services to the private sector, the
employment of private specialists on a sessional or hon-
orarium basis, the full-paying patient scheme at selected
hospitals which enables MOH specialists to receive referrals
from private hospitals, and the approval of locum practice
for MOH doctors which enables the latter to legally practice
locum in private clinics.
Nambiar (2009) argues that in the absence of formal
institutional processes and transparent institutions, privati-
zation or contracting-out may not lead to greater economic
efficiency. For example, the privatization of health support
services (pharmaceutical store and services in 1994, hospi-
tal support services in 1996, and medical examination of
foreign workers in 1997) was fraught with structural defi-
ciencies. There were no institutional structures in place prior
to privatization, regulatory companies appointed lacked the
essential capabilities required, and the appointment of an
advisory company to oversee another company promoted
overlapping roles and unnecessarily raised regulatory costs.
Consequently, concessionaires were selected despite lacking
industry experience, maintenance and monitoring of equip-
ment was not done according to guidelines, and contract
staffs were not well trained. Nambiar stresses that privatiza-
tion without the necessary institutional infrastructure reduces
potential gains, hence the importance of proper regulation,
evaluation systems, and transparency.
Mustapa, Mustapa, Ismail and Ali’s (2012) study of
increased operational costs incurred in the process of
outsourcing hospital support services hints at the possible
financial risks associated with PPPs of a similar design.
The authors note that despite the proposed benefits of
outsourcing, the practice runs the risk of incurring addi-
tional transaction costs, defined as the “ex ante costs of
drafting, negotiating, and safeguarding an agreement and,
more especially, the ex post costs of maladaption and adjust-
ments that arise when contract execution is misaligned as
a result of gaps, errors, omissions, and unanticipated dis-
turbances; (and) the cost of running a system” (“Overview
of Outsourcing”). In Malaysia, the cost of health care sup-
port services increased from £25 million in 1996 to nearly
£69 million in 1997. General cost increases were attributed
to costs arising from compliance and quality assurance
mechanisms, and the preparation and negotiations associ-
ated with concession agreements. Moreover, the transfer of
the workload to private providers resulted in risk-averse
behavior. Private providers also increased contract prices
to cover perceived higher risk. While poor record man-
agement makes it impossible to pinpoint outsourcing as
the sole cause of increased operational costs, the authors
nonetheless caution that “managing understanding, efficacy
and transparent relationship between the service provider
and the host organisation is very crucial . . . (without) a
transparent understanding of the management strategies and
having mutual understanding with vendors, the choice to
outsource might result in bad consequences” (“Overview of
Outsourcing”).
 PUBLIC–PRIVATE PARTNERSHIPS IN HEALTH IN MALAYSIA
Similarly, Babar and Izham’s comparison (2009) of
pre-privatization drug prices versus post-privatization
drug prices suggests that contracting-out practices in
PPPs can result in greater inequity and higher consumer
burdens if price regulation is lax and monopolies exist.
Pre-privatization prices (1994) were compared with
post-privatization prices (1995–1996), which in turn
were compared with those of 1997–2000. Furthermore,
1997–2000 prices were compared with those of 2001–2003.
The findings were that prices increased by 10.42% in
1995–1996, decreased by 3.37% in 1997–2000, and
increased by 64.04% in 2001–2003. Some price increases
were several hundred-fold compared with the previous year,
and did not follow any pricing formula. The authors note
that these price increases pose a hurdle to drug accessibility,
and recommend that a medicine pricing policy and rational
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pricing structure be instituted to ensure transparent pricing.
These studies indicate that strict government monitoring and
regulation of PPPs is essential in order to maintain equity
and prevent excessive cost increases.
In contrast, the provision of dialysis services in Malaysia
has been hailed as a largely successful PPP. Lim, Goh, Lim,
Zaher, and Suleiman’s study (2010) argues that government
reforms to encourage private providers to provide dialysis
treatment (while taking care to subsidize needy patients and
ensure a level playing field instead of practicing “crony capi-
talism”) has resulted in greatly expanded and fairly equitable
access to dialysis services. Between 1990 and 2005, dialysis
treatment rates in Malaysia increased more than eightfold,
reaching a level comparable to rates in developed countries.
This transformation was brought about largely through the
Malaysian government’s large-scale purchase of dialysis ser-
vices from the highly competitive private sector. In 1999, the
MOH allocated additional funds to develop more public dial-
ysis facilities and provided matching capital grants to NGOs.
Alongside reimbursements and subsidies for private sector
dialysis treatments instituted by government-run bodies (i.e.,
the Social Security Organization, Islamic Baitumal social
welfare organizations, and the Public Services Department),
the MOH also began subsidizing dialysis at private facili-
ties for eligible patients in 2001. The current government
policy is that all qualified providers may offer their ser-
vices to patients eligible for public financial assistance, and
that the government will reimburse providers for each treat-
ment episode. Eligible patients are generally free to choose
their providers, who have to compete for business. The gov-
ernment also permitted private-sector employees to train
at public institutions to become nephrologists and dialysis
nurses, and lifted restrictions to allow other practitioners—
such as general physicians and nurse aides—to perform
some duties and thus help to meet the demand for dialy-
sis workers. Reasonable regulations and low-entry barriers
have also helped to make the Malaysian dialysis market
one of the most competitive markets in the world. Private
509
dialysis provision has expanded rapidly, and the cost of pri-
vate hemodialysis treatment (adjusted for inflation) has in
turn decreased by 45% from 1990 to 2005. Thus, the authors
argue that the large-scale public financing of private dialysis
alongside the provision of physical and human resources to
rapidly expand a competitive market and increase efficiency
(without reducing quality or equity) should provide a model
for further health care partnerships.
Another successful area in PPPs in Malaysia lies in
the area of promotion of medical tourism (Chee, 2010).
While the studies identified were mainly comparative stud-
ies between Malaysia and other Southeast Asian countries
(Chee, 2010; Pocock & Phua 2011), there were salient
points to take note of with respect to the actions of the
Malaysian state. Chee contends that Malaysia was amongst
the first Asian countries to promote international medi-
cal travel as a way to earn foreign exchange. As opposed
to some of the European welfare states, developing Asian
countries had few reservations about getting onto the med-
ical tourism bandwagon. The 1997 Asian financial crisis
diverted many Malaysian health care consumers from pri-
vate facilities to public facilities, with the latter witnessing
an 18% increase in patients (Wong, 2008). Currency depre-
ciation also resulted in price increases of between 20%
and 120% for imported pharmaceuticals and medical sup-
plies (Rabobank International Asia Pacific, 1999). Private
hospitals experienced 4–9% deterioration in their operating
margins (Rabobank International Asia Pacific, 1999). Private
hospitals responded by promoting their facilities and services
abroad, and the government stepped in to assist by setting up
the National Committee for the Promotion of Medical and
Health Tourism (MNCPHT) (MOH, 2002).
This current successor to the MNCPHT is the Malaysia
Healthcare Travel Council. There is also the Health Tourism
Section under the Corporate and Health Industry Division of
the MOH (MOH, 2005). The number of foreign patients has
increased almost tenfold; from 39,114 in 1998 to 374,063 in
2008, even if these figures include foreigners who are res-
idents of Malaysia and foreign visitors who needed med-
ical care while in the country (Chee, 2010). However,
the Malaysian medical tourist industry is largely regional,
with 76.8% of medical tourists coming from Indonesia
during 2006–2008, and smaller proportions coming from
Japan (3.4%), Europe (2.7%), and India (1.8%) (Malaysian
Tourism Promotion Board, 2006, 2007, 2008). Revenue from
medical tourism is of great significance to certain private
hospitals in Malaysia; for example, about 20% of the patients
in the Pantai hospitals chain are foreign (Nomura Asia
Healthcare Research Team, 2009).
The Malaysian state also carries out other efforts to
develop and support the medical tourist industry. Regulations
related to the advertising of medical services were relaxed.
A national accreditation system, based on collaboration
between the MOH and the Malaysian Society for Quality
 510 PHUA, LING, AND PHUA
in Health (MSQH), was set up as a cheaper alternative to
the more expensive Joint Commission International (JCI)
accreditation scheme. Tax incentives were also given to pri-
vate hospitals, allowing them to claim double deduction for
expenses incurred on overseas promotion of their services.
Revenues from foreign patients were also exempted from
corporate tax. The Malaysian government also organizes
and conducts medical tourism road shows and marketing
promotions.
Proponents of medical tourism argue that it earns for-
eign exchange, contributes to the economy, and helps less
developed countries escape from dependency on extractive
industries. On the other hand, critics have voiced their con-
cerns over the effect of medical tourism on the rest of the
national health care system and the allocation of health-
related human resources. Chee argues that the problem of
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outflow of public sector medical expertise to the private sec-
tor has been exacerbated by medical tourism. Many of these
arguments are echoed by Pocock and Phua (2011), who also
contend that because trade and tourism are international in
scope while health care coverage is a national matter, the
chances of policy incoherence are high. There needs to be
convergence of the goals of the health, trade, and tourism
ministries.
The rising demand for medical personnel has also led
to the growth of public–private cooperation in the setting
up of private medical schools and training of medical stu-
dents in Malaysia. Some medical schools are government-
initiated partnerships with reputable overseas universities
(e.g., Malaysia’s Perdana University and its graduate medi-
cal program established in partnership with Johns Hopkins
University). Some overseas universities have also been
invited to set up campuses and medical schools in Malaysia
(e.g., Australia’s Monash University and its medical school
at its campus in Malaysia). Medical students in private med-
ical schools can include those sponsored by government
agencies. Government hospitals are often used as teach-
ing hospitals by private medical schools under agreements
with the MOH. An example would be Seremban Hospital,
which serves as the teaching hospital of the private sec-
tor International Medical University (IMU). The lecturers
of IMU are expected to contribute some of their time to
Seremban Hospital patient services while MOH specialist
doctors are also expected to assist in the teaching of IMU
medical students.
The WHO’s 2011 report has recognized the success of
PPP harm reduction efforts in Malaysia. The report deems
strong government leadership and sustained partnerships
among government agencies and NGOs as a key element
of Malaysia’s success in having integrated harm reduction
into the national strategic plan on drugs and HIV/AIDS.
Two core programs—the methadone maintenance therapy
(MMT) project and the needle and syringe program (NSP)—
were launched in 2005 and 2006, respectively, and expanded
dramatically over 5 years. The WHO (2011) notes that
elements of good practice in the expansion include:
the rapid scale-up of a comprehensive range of harm reduc-
tion services made available through a variety of outlets and
settings; deployment of effective policies and procedures to
guide implementation and monitoring and evaluation (M&E)
of programmes; accreditation and registration of service
providers as well as parallel training and capacity build-
ing; allocation of significant proportions of the national
budget to support implementation; excellent collaboration,
communication and partnerships between the stakeholders
involved in the national response to drugs and HIV/AIDS;
high-level commitment and support from key agencies from
various sectors; and integration of harm reduction services
into existing health systems. (n.p.)
The WHO also notes that the best practices of NSPs lie in:
. . . the existence of high-level commitment and dedicated
staff on the frontlines . . . (exemplified by) the rapid scale-
up of services and expansion of coverage to meet national
targets, along with significant financial investments by the
government in the national programme . . . (in) addition,
the diversity of NSP access points as well as their growing
integration with other health and social care services demon-
strates that a sophisticated health systems approach was put
in place to scale up NSPs, in parallel with MMT services,
primary health care, health education and referral networks.
. . . PWUD (persons who use drugs) have been empowered
to take an active role in the delivery of essential services and
have been provided official licence by the authorities. (n.p.)
The success of both programs is evident in increased access
and client response to treatment services. While the first pilot
MMT project began in 17 centers in 9 states, as of June
2010, 211 MMT access points including 21 registered pri-
vate clinics and 200 general practitioners (GPs) dispensed
methadone and other substitution drugs. As of June 2010, an
estimated 20,000 individuals were accessing fee-based sub-
stitution therapy through private practitioners, exclusive of
another 13,471 individuals registered at the 211 free MMT
service outlets. As for NSPs, three pilots were implemented
in 2006 through local NGOs; by 2010 more than 20 NGO-
based NSP sites were in operation and complemented by
NSPs at health clinics, with an overall total of 24,999 clients
served. However, while the WHO praises the high degree
of cooperation and collaboration, consistent support, and
transparency levels between government and civil society
groups, it also argues that certain components require further
attention. These include
human resource capacity across all interventions, revision,
and development of standard operating procedures (SOPs)
for each intervention in the comprehensive harm reduction
 PUBLIC–PRIVATE PARTNERSHIPS IN HEALTH IN MALAYSIA
package, the need for rapid scale-up of coverage of key inter-
ventions, especially counselling, and condom distribution,
harmonisation of laws with existing practices and decisions
in the country, as well as the development of a national
communication strategy. (n.p.)
It should be noted that private sector GPs generally pre-
scribe suboxone instead of methadone to their patients. The
former is more expensive and results in increased costs for
the patient. GPs have also expressed concern over the time
needed for follow-up and counseling of Persons Who Use
Drugs (PWUDs) and worry about financial constraints of
government fee reimbursement levels being set too low to
cover operational costs.
Other studies of harm reduction PPPs in Malaysia note
strengths and weaknesses of past and present practices
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which are worthy of attention. Narayanan, Vicknasingam,
and Robson (2011) observe that apart from being front-
line players in program implementation, NGOs have served
as a crucial bridge between state, civil society, and other
stakeholders. NGOs were well positioned to convince inject-
ing drug users to opt for medical treatment, educate their
partners, draw academics and medical practitioners into
advocacy efforts, and engage the religious lobby of Malaysia
while deflecting criticisms from unconvinced Islamic groups
away from the state (albeit with varying degrees of suc-
cess). On the subject of compliance issues, Vicknasingam
and Mazlan (2008) note that prior to the MMT program,
the government implemented an agonist maintenance treat-
ment program using buprenophrine mono-tablets in 2001.
From 2001 to 2005, more than 500 medical practitioners
treated about 30,000 dependent individuals; however, the
practice was marred by occasions of buprenophrine mis-
use. Physicians were found prescribing large quantities of
buprenophrine for unsupervised use and patients were not
provided drug counseling and other psychosocial services.
As a result, the government limited the use of buprenophrine
at the end of 2006. In a more recent 2010 study of MMT
practices at a NGO-run center and private clinic, Mohamad,
Bakar, Musa, Talib, and Ismail discovered that lower dosages
of MMT were routinely prescribed despite clear guidelines
on MMT dosages, resulting in lower retention rates. The
authors concluded that “ophophobia” among doctors—as
indicated by the hesitation of doctors to prescribe opiates out
of fear of promoting addiction—results in inadequate doses
and premature termination of MMT. The authors conclude
that this problem must be remedied through further edu-
cation of health professionals and extensive monitoring to
ensure that guidelines are adhered to.
Lastly, Colombini, Ali, Watts, and Mayhew’s study
(2011) of One-Stop Crisis Centres (OSCC) suggests possible
reasons which contribute to the failure of PPP arrangements,
and reveals examples of institutional and structural difficul-
ties that PPPs may face at the ground level, in particular
511
where NGO involvement is concerned. The 1996 OSCC
policy aimed to link clinical services and NGO support
(i.e., legal aid, counseling, and religious support) for abused
women who show up at hospitals. Although the policy was
top-down and formulated by the MOH, the policy document
of 1996 had no clear objectives, no proper guidance for repli-
cation, no allocated funds, and no monitoring system. The
roles of NGOs were not clearly defined and this resulted
in hospitals expecting NGOs to take on more than they are
able to do without state financial support. The debate over
who should be responsible for delivering and funding the
OSCCs’ nonclinical services led to rifts between NGO and
hospital staff. Furthermore, the MOH’s lack of prioritization
of OSCCs and general loss of political support for domes-
tic violence concerns led to the decline of OSCC services.
A follow-up study by Colombini, Mayhew, Ali, Shuib, and
Watts (2012) focusing on the implementation of OSCCs at
different hospitals reveals that practices at individual hos-
pitals were influenced by organizational constraints such as
a lack of clarity in standard operational procedures (SOPs),
lack of training on domestic violence, a scarcity of on-site
specialized staff, time constraints, limited allocated budgets,
and limited referral options for abused women. Although the
OSCC policy was nationally implemented, the model was
constrained by local resources and marked by fragmentation
at the local hospital level, suggesting that a single integrated
model is not possible for all levels of hospital care across all
regions. Both studies imply that in order to create successful
and sustainable PPPs—especially when NGOs are involved
and staff and resource limitations are a concern—it is impor-
tant to have institutional support in the form of clear policy
guidance over roles, responsibilities, and operational details,
as well as sustained financial support for the expansion of
programs and services.
DISCUSSION
The government of Malaysia embarked on the path of pri-
vatization as early as 1983 under the premiership of Dr.
Mahathir Mohamed. This policy was continued under subse-
quent Prime Ministers. More recently, the strategy of “PPPs”
was adopted and a UKAS was actually established in the
influential Prime Minister’s Department in 2011. Malaysia’s
experience with privatization and PPPs may hold useful
lessons for other nations. The record is mixed, with successes
and failures. This review was carried out to identify rigor-
ous (i.e., going beyond mere description) studies of health
care PPPs in Malaysia and to identify factors that made these
PPPs “successes” or “failures”.
Some “successful” PPPs we identified include the provi-
sion of dialysis services, harm reduction programs (MMT
and the NSP), the promotion of medical tourism, and the
production of more health care personnel through private
 512 PHUA, LING, AND PHUA
medical education. With respect to the provision of dialysis
services, this was a “success” because access was greatly
improved without incurring high costs for the government
and without endangering patients through low quality care.
The MMT and NSP programs can also be considered “suc-
cesses” for similar reasons.
In the case of medical tourism, although clients are mostly
from neighboring countries such as Indonesia, the participa-
tion of public bodies such as the Malaysia Healthcare Travel
Council has helped to boost the number of arrivals and rev-
enues generated. However, critics have pointed out that the
growth of medical tourism may accelerate the outflow of
experienced health personnel from the public sector to the
private sector.
In the case of private medical education, the help given by
the government (such as allowing public hospitals to be used
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as teaching hospitals by the private sector) has led to signif-
icant growth in this area. This “success” has led to worries
about overproduction of doctors, nurses, and pharmacists in
the near future.
The (arguable) “failures” include drug procurement via
privatized agencies, the contracting out of hospital support
services, and the program to deal with domestic violence via
OSCCs. These can be considered “failures” mainly because
of the financial dimension; that is, costs of drug procure-
ment and hospital support services increased significantly
after privatization and contracting out. The domestic vio-
lence program failed partly because of lack of resources but
also because of policy and organizational confusion.
CONCLUSION
Despite the limited number of PPPs surveyed above, gen-
eral conclusions can be drawn on the factors influencing
failures or successes of health PPPs in Malaysia. Critical fac-
tors for success include regulation, transparency, clear policy
guidance and clarity on operational procedures and respon-
sibilities, proper evaluation mechanisms, sustained financial
support (especially for NGO partners), and unwavering com-
mitment from policy-makers to see the partnerships through.
Care must be taken to ensure that the potential costs of
PPPs—such as increased public financial commitments as
a result of contracts and subsidies that go awry, time and
resources spent on regulation and monitoring of performance
by private sector for-profit and NGO partners, and poten-
tial misuse and abuse as a result of noncompliance—do not
outweigh or overshadow the anticipated benefits of these
partnerships.
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