1. Health Care Transformation The Way Forward Prof Awang Bulgiba Awang Mahmud MBBS MPH MAppStat PhD FFPH FPHMM FAMM FASc Deputy Vice-Chancellor (Research & Innovation) University of Malaya

2. Malaysian population of 28.9 million in 2011 (63% between 15 to 64 years old, 32% below 15 and 5% above 65) Life Expectancy: male 71.9, female 77.0 Crude birth rate is 17.5 per 1000 population Crude death rate is 4.8 per 1000 population Infant mortality rate is 6.8 per 1000 live births Maternal mortality rate is 27.3 per 100,000 live births Total expenditure on health RM33.7 billion or USD10.8 billion Total Expenditure for Health as a percentage of Gross Domestic Product (GDP) was 4.96% of GDP 2 Health Status of Malaysians (2011) 3. Top 3 causes of admissions at public hospitals pregnancy and childbirth diseases of the respiratory system injuries and poisoning Top 3 causes of death in MoH hospitals heart diseases respiratory diseases infectious & parasitic diseases All childhood immunisation coverage more than 90% 3 Health Status of Malaysians 4. Awang Bulgiba Awang Mahmud 4 5. Privatisation of Healthcare in Malaysia Share of private healthcare expenditure rising 5.8% in 1981 7.6% in 1982 45.4% in 2009 Launch of the Privatisation Master Plan (PMP) in 1991 included healthcare for private ownership; 12 public hospitals were among 149 agencies identified for privatisation in Peninsular Malaysia Proliferation of private healthcare facilities 174 in 1992 660 in 2011 5 6. Awang Bulgiba Awang Mahmud 6 7. From 1956 to 2011 Awang Bulgiba Awang Mahmud 7 Health facility 1956 2011 Community clinics 26 1,864 Health clinics 16 985 Private clinics - 6,589 Government hospital & institutions 65 146 Private hospitals 50 220 8. Awang Bulgiba Awang Mahmud 8 Current scope of services in health clinics Curative Services Family Health Dental Services Nutrition and Dietetics Health Education/Promotion Home Nursing, Care of the Elderly Rehabilitative Services Environmental Sanitation Well Women Clinics Adolescent Health Community Mental Services, etc 9. Awang Bulgiba Awang Mahmud 9 The Future of Malaysian Public Health Care 10. We face many problems today Healthcare costs are rising rapidly Double burden of diseases Lifestyle & environmental diseases (CVD-related, cancers) Emerging and re-emerging infectious diseases 40% of doctors serve 80% of population 60% of doctors serve 20% of population Health research is not optimal Awang Bulgiba Awang Mahmud 10 Despite our enviable health status 11. Double burden of diseases Lifestyle & environmental diseases (CVD-related, cancers) Emerging and re-emerging infectious diseases Costly to treat Curative care taking precedence over preventive care Suboptimal use of expensive diagnostic & therapeutic options Suboptimal preventive care leading to rise in lifestyle diseases Awang Bulgiba Awang Mahmud 11 Rising healthcare costs 12. No national health data warehouse Poor interfacing between private, public and university facilities Barriers between private, MOH and university facilities Suboptimal use of chip-based Identity Card Lack of integrated emergency response plan Fragmented ambulance service Awang Bulgiba Awang Mahmud 12 Lack of integrated care 13. We have gone through half a dozen DGs of Health No NHFS is in sight Rising healthcare costs makes this problem worse by the day Rising healthcare costs contributed by proliferation of private facilities introduction of expensive curative services over cheaper preventive services sub-optimal use of expensive services in private & public sector We badly need an NHFS & a way to finance the care of a rapidly ageing population Awang Bulgiba Awang Mahmud 13 Lack of National Healthcare Financing System 14. Awang Bulgiba Awang Mahmud 14 The Malaysian experience (summary) The government has always been the main provider of health care in Malaysia Preventive care has almost exclusively been the preserve of the government From the 1950s until recently, the government was the only one providing preventive care The private sector has always concentrated on curative care 15. We need to be ready for some Grand Challenges of the Future NOW Awang Bulgiba Awang Mahmud 15 16. 1. Rise in lifestyle diseases 2. Ageing population 3. Rapidly spreading infectious diseases The 3 Grand Challenges of the Future Awang Bulgiba Awang Mahmud 16 17. Rise in lifestyle diseases (heart disease, cancers) in tandem with sedentary lifestyles & environmental changes Preventive and promotive care is more cost effective than curative care We need a healthcare system & healthcare financing model that recognises this fact Lifestyle diseases Awang Bulgiba Awang Mahmud 17 18. We do not want this to be commonplace in the future 19. Awang Bulgiba Awang Mahmud 19 20. 20 21. By 2035, >10% of Malaysias population will be 60 years or older Health care must recognise this fact and take steps to prepare for it The future healthcare system must cater for this group of people Ageing population Awang Bulgiba Awang Mahmud 21 22. Retirement homes like this may become commonplace in the future 23. Awang Bulgiba Awang Mahmud 23 24. Emerging and re-emerging diseases pose a major threat to Malaysians today Ability to harness all healthcare resources is key to controlling outbreaks Rapidly spreading infectious diseases Origin & spread of the Black Death in Asia Awang Bulgiba Awang Mahmud 24 25. Heat-map Visualisation Published on Apr 20, 2012 This is a heat-map visualization of the prevalence of flu in New York City, as observed through public Twitter data. The more red an area is, the more people are afflicted by flu at that location. Emergent aggregate patterns are easily discovered with a second-by-second resolution. 26. Awang Bulgiba Awang Mahmud 26 27. Infectious diseases spread faster than ever before Awang Bulgiba Awang Mahmud 27 28. Let us take a look at how quickly H1N1 spread throughout the world 29. Awang Bulgiba Awang Mahmud 29 30. Chikugunya is here Awang Bulgiba Awang Mahmud 30 31. All these aided in part by the fact that almost everyone can fly 32. Awang Bulgiba Awang Mahmud 32 33. A NEW healthcare financing model A WORLD CLASS School of Public Health Better use of ALL public and private healthcare facilities during emergencies Better integration & sharing of data between agencies Awang Bulgiba Awang Mahmud 33 What is needed 34. A World Class School of Public Health Awang Bulgiba Awang Mahmud 34 35. Malaysia badly needs a world class School of Public Health Advanced training for future public health professionals Advocacy for a better quality of life Advisory role to governments & NGOs Active involvement in niche areas Awang Bulgiba Awang Mahmud 35 36. Malaysias School of Public Health needs to prepare itself to meet these Grand Challenges Staff capabilities will need to increase dramatically Lifestyle disease expertise Ageing issues expertise Real-time spatio-temporal infectious disease modelling Quick response infectious disease team Health policy advisory roles Better working relationship with private healthcare, universities & other agencies dealing with healthcare Interfacing of data from other agencies School of Public Health Awang Bulgiba Awang Mahmud 36 37. Expertise The list of experts in the country needs to grow The depth of expertise also needs to grow Malaysia will need to invest heavily in these areas: Capacity building Building up selected resources & facilities Extending and strengthening collaborative networks Awang Bulgiba Awang Mahmud 37 38. Awang Bulgiba Awang Mahmud 38 39. More funds for preventive care Awang Bulgiba Awang Mahmud 39 40. Awang Bulgiba Awang Mahmud 40 21.35 61.12 10.22 1.85 1.62 3.84 % of MOH Budget PublicHealth Medical Administration Research and Tech.Support One-off 41. Awang Bulgiba Awang Mahmud 41 Preserve of governments Some preventive care will always remain the preserve of the government International health Relates to control of ports and airports Control of epidemics will always be the preserve of the government because Epidemic control is expensive with no reward High level labs like BSL3 labs are expensive to build and maintain 42. Awang Bulgiba Awang Mahmud 42 A different take on preventive care In US preventive care is only now being provided for by private health care providers The reason is probably caused by the rise of managed care (payments based on capitation) In Msia some preventive care is carried out by GPs (vaccinations) The driving force is not managed care but because it is profitable Hopefully, there will be greater emphasis on preventive & promotive care within the next 10 years The driving force is likely to be a change in the health financing model 43. That Malaysian public healthcare of the future will have the following features: 1. Place greater emphasis on preventive and promotive rather than curative care to address the epidemic of lifestyle diseases 2. See greater integration between public and private healthcare facilities and academia to address the problem of equitable access and care of an ageing population 3. Be more integrated for better epidemiological control of emerging infectious diseases and non-communicable diseases Awang Bulgiba Awang Mahmud 43 I hope 44. 44 45. A New Health Care Financing Model 45 46. Awang Bulgiba Awang Mahmud 46 A new health care financing model A change in the financing mechanism If the financing mechanism changes from the present one to a more inclusive national healthcare financing scheme, this is likely to change Malaysia is unlikely to follow a managed care model It is more likely to follow a tax-funded health insurance model There is likely to be a blurring in the line between public & private health care It is my hope that this model will be less likely to reward use but more likely to reward doctors for keeping their patients healthy 47. Awang Bulgiba Awang Mahmud 47 Hopefully the new model will be more likely to reward GPs for keeping patients out of hospitals this is similar to what is happening in the NHS whereby Primary Care Trust doctors are rewarded for keeping patients out of hospitals this has the same effect as a managed care model with its payment based on capitation will integrate the private and public healthcare facilities so that better use can be made of such facilities 48. Awang Bulgiba Awang Mahmud 48 Some challenges will result from Consumer perceptions and demands Making more consumers prefer primary care rather than specialist care Restricting specialist care to those who require it Primary Care Physicians Making them the gatekeepers of the health care system Changing the entire system of health care Technology Making IT the enabler for all this Environment Making the environment conducive for this to happen Cost of health care Making the new healthcare model a reality Getting all parties to agree Community participation Making the community the driving force behind health care 49. Public health care Academia Private health care Health Care Financing Model Awang Bulgiba Awang Mahmud 49 50. We need to think of a new way to approach our health care We need to dream BIG Awang Bulgiba Awang Mahmud 50 51. Awang Bulgiba Awang Mahmud 51 52. The future of health care in Malaysia is uncertain but we can do something about it now 53. Awang Bulgiba Awang Mahmud 53 54. Awang Bulgiba Awang Mahmud 54 55. Awang Bulgiba Awang Mahmud 55 56. 56