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A Political Analysis of Health Care Reform in Malaysia

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A Political Analysis of Health Care Reform in Malaysia A Political Analysis of Health Care Reform in Malaysia The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:37945644 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA A POLITICAL ANALYSIS OF HEALTH CARE REFORM IN MALAYSIA ZINA MAAN JARRAH A DELTA Doctoral Thesis Submitted to the Faculty of The Harvard T.H. Chan School of Public Health in Partial Fulfillment of the Requirements for the Degree of Doctor of Public Health Harvard University Boston, Massachusetts. May 2018 Thesis Advisor: Dr William C. Hsiao Zina Maan Jarrah A Political Analysis of Health Care Reform in Malaysia Abstract This thesis explores the political economy of health care reform in Malaysia by examining two policies in depth: first, transformation from National Health Service towards social health insurance, known as 1Care; and second, an incremental step in the form of non- profit, socially-oriented voluntary health insurance (VHI). The Analytical Platform proposes the following problem statement: there is an insufficient understanding of the institutional and political barriers to health care reform in Malaysia. The chapter presents a literature review to provide the conceptual and scientific foundation of knowledge for the thesis. Next, the chapter describes Malaysia’s political environment and health system in detail, including previous attempts at reform. Results Statement Part I presents a retrospective political analysis of Malaysia’s 1Care reform, which investigates the fundamental causes of the reform’s failure. This is achieved by conducting a stakeholder analysis using Reich’s PolicyMaker tool and methodology, to elucidate interest groups’ power and position on the reform; then by applying Kingdon’s multiple streams framework to provide context for the reform’s failure within the agenda- setting process. The overarching conclusion of this analysis is that, although opposition groups made considerable efforts to derail 1Care, the underlying cause of the reform’s failure was the lack of continuous and demonstrable political support by the Prime Minister and ruling coalition. Results Statement Part II seeks to provide relevance to the current policy environment by extracting lessons learned from 1Care that can be applied to the ongoing non-profit VHI ii scheme. Where comprehensive reforms failed, this chapter examines whether a relatively small-scale, incremental step such as VHI can be leveraged towards achieving longer-term goals. The findings from this analysis highlight the inherently political nature of health care reform and reinforce the crucial need to conduct political economy analysis to develop reforms that are both technically optimal and politically feasible. iii Table of Contents Abstract ................................................................................................................................................... ii List of Tables .......................................................................................................................................... vi List of Figures ....................................................................................................................................... vii Acknowledgements ............................................................................................................................... viii CHAPTER 1: INTRODUCTION ............................................................................................................. 1 CHAPTER 2: ANALYTICAL PLATFORM ............................................................................................. 6 2.1 Introduction ............................................................................................................................. 6 2.1.1 Problem statement........................................................................................................... 8 2.2 Relevant literature in political analysis of health reform ....................................................... 9 2.2.1 Theory and analytical frameworks ................................................................................. 9 2.2.2 Political barriers to reform: country experiences and mitigation strategies ................ 14 2.2.3 Key takeaways: Literature review and country experiences ......................................... 18 2.3 Malaysia’s health system ...................................................................................................... 19 2.3.1 Demographics and health system performance ............................................................ 21 2.3.2 Delivery ......................................................................................................................... 25 2.3.3 Financing ...................................................................................................................... 30 2.3.4 Key takeaways: Malaysia’s health system .................................................................... 34 2.4 Malaysia’s political system and previous health care reforms ............................................. 35 2.4.1 Politics in Malaysia ...................................................................................................... 37 2.4.2 Health system reforms prior to 1Care .......................................................................... 46 2.4.3 Key takeaways: Malaysia’s political system and previous health reforms ................... 49 CHAPTER 3. RESULTS STATEMENT PART 1: ‘1CARE FOR 1MALAYSIA’ – AN APPLIED POLITICAL ANALYSIS ........................................................................................................................ 52 3.1 Introduction ........................................................................................................................... 52 3.1.1 The 1Care for 1Malaysia proposal ............................................................................... 54 3.1.2 Goal and structure of this chapter ................................................................................ 55 3.2 Methodology ......................................................................................................................... 56 3.2.1 Conceptual Framework ................................................................................................. 56 3.2.2 Data ............................................................................................................................... 60 3.3 1Care for 1Malaysia: A description and timeline of the reform ........................................... 64 3.3.1 Policy description ......................................................................................................... 64 3.3.2 Timeline of 1Care.......................................................................................................... 72 3.4 Stakeholder analysis ............................................................................................................. 79 3.4.1 Overview of stakeholders, power, interest, and position .............................................. 81 3.4.2 Stakeholder interests ..................................................................................................... 92 iv 3.4.3 Analysis of stakeholder coalitions against 1Care ....................................................... 103 3.4.4 Stakeholder mapping: power and position ................................................................. 108 3.5 Applying Kingdon’s multiple streams approach: what factors led to the failure of 1Care? 112 3.6 Discussion ........................................................................................................................... 120 3.6.1 Fundamental causes of 1Care’s failure ...................................................................... 120 3.6.2 Limitations .................................................................................................................. 122 CHAPTER 4. RESULTS STATEMENT PART 2: APPLYING LESSONS FROM 1CARE TO CURRENT REFORM EFFORTS ........................................................................................................................... 124 4.1 Introduction ......................................................................................................................... 124 4.1.1 The VHI reform ........................................................................................................... 125 4.1.2 Goal and structure of this chapter .............................................................................. 126 4.2 Methodology ....................................................................................................................... 128 4.2.1 Conceptual framework ................................................................................................ 128 4.2.2 Data ............................................................................................................................. 129 4.3 Non-profit VHI: where is it now? ....................................................................................... 129 4.3.1 Policy description ....................................................................................................... 129 4.3.2 Timeline
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