MALAYSIA HEALTH SYSTEMS RESEARCH VOLUME I Contextual Analysis of the Malaysian Health System, March 2016 Table of Contents Acknowledgments .........................................................................................................5 Glossary of Acronyms ..................................................................................................30 Executive Summary .....................................................................................................35 1. Introduction 42 1.1. Objectives of the Report and Context of MHSR ..............................................42 1.2. Brief History of Malaysia’s Health System .......................................................43 1.3. Health System Objectives and Priorities ..........................................................44 2. Health System Performance: Ultimate Outcomes 46 2.1. Population Health Outcomes ..........................................................................46 2.2. Population Health Outcomes: Equity ..............................................................59 2.3. Financial Risk Protection .................................................................................63 2.4. User Satisfaction ............................................................................................65 3. Health System Performance: Intermediate Outcomes 69 3.1. Access ...........................................................................................................69 3.1.1. Physical Access .......................................................................................69 3.1.2. Utilization .................................................................................................70 3.2. Quality ............................................................................................................72 3.2.1. Efectiveness and Comprehensiveness of Care ........................................72 3.2.2. Responsiveness .......................................................................................83 3.3. Efciency ........................................................................................................85 3.3.1. Allocative Efciency ..................................................................................87 3.3.2. Technical Efciency ................................................................................. 91 Tis report is intended only for the use of the individual entity to which it is addressed and may contain 1 information that is privileged, confdential, and exempt from disclosure. 4. Emerging Opportunities and Challenges 93 4.1. Demographic and Epidemiological Transitions 93 4.1.1. Ageing 93 4.1.2. Non-Communicable Diseases ..................................................................94 4.2. Cost Growth .................................................................................................109 4.3. Opportunities ...............................................................................................112 5. Health System Functions: Overview 114 5.1. Organization and Governance ......................................................................114 5.2. Service Delivery ............................................................................................115 5.2.1. Overview ................................................................................................115 5.2.2. Primary Health Care (Medical) ................................................................116 5.2.3. Secondary and Tertiary Health Care .......................................................121 5.2.4. Oral Health ............................................................................................126 5.2.5. Human Resources for Health .................................................................128 5.2.6. Health Information Systems ...................................................................130 5.3. Financing ......................................................................................................133 5.3.1. Health Expenditure Trends and Financing Patterns ................................133 5.3.2. Funding Flows and Budget Allocation ....................................................136 5.3.3. Equity in Financing and Beneft Incidence Analysis .................................137 5.3.4. Fiscal Space Analysis .............................................................................138 5.3.5. Projection Modeling ...............................................................................142 5.3.6. Private Health Insurance ........................................................................143 5.4. Provider Payment Mechanisms ....................................................................144 2 Tis report is intended only for the use of the individual entity to which it is addressed and may contain information that is privileged, confdential, and exempt from disclosure. Table of Contents 5.4.1. Public Sector Payment Mechanisms ......................................................144 5.4.2. Private Sector Payment Mechanisms .....................................................146 6. Diagnosing Causes of Health System Performance 149 6.1. Summary of Performance Findings ...............................................................149 6.2. Supply-Side Factors .....................................................................................151 6.2.1. Financing ...............................................................................................151 6.2.2. Payment Incentives and Purchasing .......................................................152 6.2.3. Organizational Structure of the Delivery System .....................................153 6.2.4. Human Resources and Training .............................................................156 6.2.5. Management .........................................................................................157 6.2.6. Physical Inputs .......................................................................................158 6.3. Demand-Side Factors ..................................................................................158 6.3.1. Physical Access .....................................................................................159 6.3.2. Financial Access ....................................................................................160 6.3.3. Health Producing Behaviors ...................................................................160 6.3.4. Awareness of Need and Health Seeking Behavior ..................................160 6.3.5. Quality Perceptions ................................................................................161 6.4. Implications for Policy ...................................................................................162 7. Conclusions 164 References 166 Appendix 1: Malaysia Health Systems Research Methodology and Working Arrangements 172 Appendix 2: Ministry of Health Organizational Charts 175 Tis report is intended only for the use of the individual entity to which it is addressed and may contain 3 information that is privileged, confdential, and exempt from disclosure. 4 Tis report is intended only for the use of the individual entity to which it is addressed and may contain information that is privileged, confdential, and exempt from disclosure. Acknowledgments Maria El Koussa Visiting Scientist, Harvard T.H. Chan School of Public Health Research Team AcknowledgmentsPost-Doctoral Research Fellow, Harvard T.H. Chan School of Dr. Dian Kusuma Research Team Public Health TheKai MalaysiaShen Lim Health SystemsVisiting Scientist, Research Harvard Report T.H. was Chan written School by: of Public Health Research Team Dr. Prasadini Research Fellow, Institute for Health Policy Research Team Perera Rifat Atun, Lead Principal Investigator Dr. AmritPeter Kaur Berman, Virk Visiting Co-Principal Scientist, Investigator Harvard T.H. Chan School of Public Health Research Team Yadira Almodóvar-William Hsiao, Co-Principal Investigator Doctoral Student, Harvard T.H. Chan School of Public Health Research Team Díaz Emily Myers, Project Director Zina JarrahWei Aun Yap,Doctoral Technical Student, Director Harvard T.H. Chan School of Public Health Research Team Usman Munir Doctoral Student, Harvard T.H. Chan School of Public Health Research Team Contributions from the Harvard Team and Team Malaysia, listed below, are gratefully acknowledged. Iryna Postolovska Doctoral Student, Harvard T.H. Chan School of Public Health Research Team Dr. Daniel Vigo Doctoral Student, HarvardHARVARD T.H. Chan School TEAM of Public Health Research Team Name Designation & Organizational Afliation MHSR Role Professor of Global Health Systems and Director of the Global Lead Principal Prof. Rifat Atun Health Systems Cluster, Harvard T.H. Chan School of Public Health Investigator Professor of the Practice of Global Health Systems and Economics, Prof. Peter Berman Co-Principal Investigator Harvard T.H. Chan School of Public Health K.T. Li Research Professor of Economics, Harvard T.H. Chan Prof. William Hsiao Co-Principal Investigator School of Public Health Emily Myers Project Director, Harvard T.H. Chan School of Public Health Project Director Dr. Wei Aun Yap Visiting Scientist, Harvard T.H. Chan School of Public Health Technical Director Senior Project Coordinator, Harvard T.H. Chan School of Public Lead Administrative Courtney Bridgeo Health Organizer Prof. Margaret Associate Professor of Global Health, Harvard T.H. Chan School of Senior Advisory Team Kruk Public Health