1. Dr Abu Bakar Suleiman President International Medical University Kuala Lumpur, MALAYSIA Third Annual ETHEL Conference Bruges, Belgium 28-29 November 2002 Reengineering a National Healthcare System: The Case of Malaysia

2. Malaysian Healthcare System Overall objectives:  Improving health status & promoting social well-being well-being  Ensuring equity and access to health & healthcare & healthcare  Ensuring efficiency in the use of resources  Enhancing clinical effectiveness  Improving quality of services & patient satisfaction satisfaction  Ensuring sustainability of the system.

3. How healthcare:  supported  organised for service delivery  organised for service delivery influences country’s:  social  economic well-being  economic well-being  political  political Health services:  important segment of services industry. Malaysian Healthcare System

4. Issues and Challenges in Medicine IssuesChallenges Medical technology Increasing consumer expectations (patient self determination) Escalating healthcare costs, limited resources Changing demography living longer, changing disease pattern lifestyle diseases Chronic & degenerative diseases HIV/AIDS, Diabetes, Cardiovascular diseases, etc

5. IssuesChallenges variation in medical practice; evidence-based practice Accountability, transparency – healthcare providers Patient protection and safety Emphasis on: healthcare quality, patient safety, health outcomes, health status, quality of life (disclosure) Incentives to be aligned to above Restructuring healthcare services (IOM report” 1999, 2001) Issues and Challenges in Medicine

6. Economic, Social, Scientific Pressures on Medicine Chronic, degenerative diseases of aging Lifestyle diseases Medical technologies Increasing consumer expectations Escalating healthcare costs All countries face problems financing healthcare Anxieties about future of medicine & healthcare.

7. Economic, Social, Scientific Pressures on Medicine Policy makers: Pressures on:  efficiency, cost control Pressures on:  efficiency, cost control medical, healthcare reform medical, healthcare reform Attempts at reform: Focus mainly on:  Means of medicine, healthcare  Not goals & ends or purpose & direction of medicine. or purpose & direction of medicine.

8. 1. The prevention of disease & injury and promotion & maintenance of health 2. The relief of pain & suffering caused by maladies Hastings Centre International Consultation: The Goals of Medicine:

9. 3.The care & cure of those with a malady, and the care of those who cannot be cured 4.The avoidance of premature death and the pursuit of a peaceful death. Hastings Centre International Consultation: The Goals of Medicine: …continued

10. The Goals of Medicine:  Represent core values of medicine  Guide to practical approach:  Future priorities of biomedical research  Design of healthcare systems  How doctors should be educated.

11. Present healthcare systems:  Organised around acute catastrophic illnesses  Patients treated until they are well  Episodic, fragmented Many countries:  Health financing based on “casualty” approach of health insurance approach of health insurance  Based on fundamental unpredictability of disease & injuries disease & injuries  Expensive health systems developed based on “acute care” model. on “acute care” model.

12. In coming decades: Increased predictability of risks of disease (Lots of research still to be done) Major advances in:  Immunology  Predictive genetics & human genome project  enable to predict disease long before symptoms occur.

13. Concept of illness Not all are unpredictable or “Acts of God” Trauma, infections  remain unpredictable Trauma, infections  remain unpredictable  smaller part of burden of illness  smaller part of burden of illness Predictive genetics  illnesses that can be predicted Implications: responsibility for dealing with avoidable or manageable illnesses. Paradigm Change for Healthcare

14. Consequential to genetic predictive testing what approach to take for illness that are predictable? Social responsibility: Proactive management:  avoidance  early management  early management  risk factors and illness  risk factors and illness ? Continue to consider it as “accidents” Balance: Individual responsibility for Societal cost of care. Societal cost of care. Paradigm Change for Healthcare

15. Health financing: New tools- transfer ability, moral responsibility for,  individuals  families  families  communities  communities to manage own health more effectively  Telehealth blueprint.  Telehealth blueprint. Paradigm Change for Healthcare

16.  “Early warning systems”- individual & population health population health  “Managed care”  improving:  health status  health outcomes  health outcomes  Community-based healthcare systems hospital- “back up” hospital- “back up” supports primary care  “engine” of health service delivery supports primary care  “engine” of health service delivery  Patient-centred healthcare system.  (Note: 8 goals of health system in Telehealth blueprint changing roles of: hospitals, healthcare providers, patients) Paradigm Change for Healthcare

17. Move from: diagnosis & treat, salvage topredict & early management of: health risk factors illness Major implications:  “Acute care” model of healthcare delivery  “Casualty” model of health insurance. Paradigm Change for Healthcare

18. Promote different thinking about:  health, wellness  health, wellness  illness  illness To the extent illness- predictable & manageable Passive healthcare delivery Reactivehealth financing Change to: Proactive approach that involves: individual, patient, family, community. approach Paradigm Change for Healthcare

19. Focus on:  Developing full potential in health- “wellness”  Manage individual health while still in state of “wellness”  Screen for health risk factors  Early management of identified health risk factors  Early management of illness. Paradigm Change for Healthcare

21. The Four Integrated Telehealth Pilot Projects Provides up-to-date Knowledge Empowers individual. Provides continuing up-to-date knowledge and skills to healthcare providers MCPHIE CME LHP Provide a personalized proactive and prospective lifetime health plan to achieve a continuum of care to keep the individual in the highest possible state of health Enhance capabilities of primary care centres, extend the reach of specialized healthcare, optimize the utilization of specialists and reduce patient transfers. Teleconsultation

22. Eight Goals of the Health System:  Wellness focus  Person focus  Informed persons  Self-help  Care provided at house/close to home  Coordinated, continuous, seamless care  Services tailored to individuals/groups with special needs  Effective, efficient, affordable services. Realization of 8 goals will result in achieving the vision for health.

23. Health Services Goals for the Health System of the Future 1. Wellness focus Services to promote individual wellness throughout life 2. Person Focus Focus services on the person and ensure services are available whenever & wherever required 3. Informed person Provide accurate & timely information and promote knowledge through personalized education services to enable individuals to make informed health decisions 4. Self help Increase ability of individuals & families to manage own health through knowledge transfer and interactive network- based health management tools

24. 5. Care provided at home or close to home Distributed multimedia networks to provide physical and virtual services into homes, health settings and community centres 6. Coordinated, Continuous, seamless care Manage and integrate care across different settings and episodes of care throughout life 7. Services tailored as much as possible Customize services to needs of individuals and groups with special circumstances 8. Effective, efficient affordable services Enhanced access, integration and timely delivery of quality services at affordable cost. Health Services Goals for the Health System of the Future

25. Technology enabler to realise the vision for health Emphasis on :  Health promotion  Disease prevention  Health risk assessment in management of individual, community health  Empowerment of individuals, families, communities.

26. Telehealth Blueprint Lifetime Health Plan  To facilitate continuum of care for the lifetime health data in state of wellness & illness systematically captured and available to healthcare providers  Ensures patient focused, continuous, coordinated, integrated care throughout life  Lifetime Health Record to be created

27. Telehealth Blueprint Emphasise Primary Care  Major thrust of healthcare system  Need to be extended towards management of community health, extended, shared and homecare, including self-care.

28. Need for careful review on the future role of :  Hospitals  Doctors  Nurses and other health professionals  Patients and families  Linkages between hospitals and primary care and extended care, including home care. Telehealth Blueprint

29. Promoting the Health Paradigm  Emphasize preventive and promotive aspects of healthcare  Support individuals/families make lifestyle choices that best maintain health  Provide services during state of wellness to support maintenance of health  Health system should “invert” the healthcare pyramid – secondary & tertiary care, curative services should support preventive, promotive services at primary care level,and care should be brought to the home.

30. Telehealth Blueprint Promoting the Health Paradigm Essential health services : information and education for individuals to support the wellness paradigm consultations to maintain health or to provide early treatment of illness,  all underpinned by a lifetime health plan and lifetime health record.

31. Telehealth  Technology enabler to realise vision for health  Potential to develop superior & modern health system Transformation  Empowerment of individual on health  Emphasis on services for wellness and for care  Greater involvement of patients in own health and care  Coordinated, continuous, seamless care  Development of patient- centred health services

32. Telehealth – implications for change: Telehealth – implications for change:  Structure  Process  Outcomes PresentStructure:  Independent doctors’ practices  Network of doctors Network of hospitals  Providers separate from fundersFuture  Groups of doctors’ practices integrated with hospital in a system  System & network through integrated health delivery system  Integrated financing & delivery

33. Process:  Illness focused, fragmented episodic care  Emphasis on wellness & health status  Development of services for wellness as well as for care Telehealth – implications for change: Telehealth – implications for change:  Structure  Process  Outcomes Outcome: Outcome:  Emphasis on episodes/ encounter  Quality Assurance through peer review  Emphasis on health status throughout life  Quality Assurance through outcomes measurement. Present Future

34. Present Present Health information system developed around episodes/ encounter of care, collecting information for bill collection Patient-centred Health System Future Future Health information System will be person/patient -centred, collecting health data to become lifetime health record.

35. Health Information System Present  Episodic, finance orientation  Episodic, fragmented application  Individual, provider- based  Financial measurement  Rectrospective decision support  Fee for service billing Future Future  Person/patient orientation  Enterprise-wide application  Enterprise- wide based  Financial, quality, outcomes measurement  Concurrent decision support  Delivery & financing (e.g. managed care, casemix DRG, capitation, etc.

36. Experience from developed countries – based on common goals nations set for health systems: Equity: Universal coverage General tax/ Social insurance Universal coverage General tax/ Social insurance & equal access & equal access Cost Control Strong Global budget Single channel - payment Single channel - payment Efficient use of resources High (or moderate) General tax/ Social insurance Consumer choice High Indirect provision of services Integrated services General tax/ Social insurance. Restructuring Malaysia’s Healthcare System

37. Experience from developed countries: 1. To promote solidarity, social justice:  financing to be organised into explicit systems  government  centre of decision making  allocation & use of resources  allocation & use of resources  ensure achievement of national health policies.  ensure achievement of national health policies. Restructuring Malaysia’s Healthcare System

38. Experience from developed countries: 2. To achieve:  universal & equal access to healthcare  control health expenditure  ensure efficient use of resources Financing Financing Organisation of payment & delivery Organisation of payment & delivery must be integrated. Restructuring Malaysia’s Healthcare System of healthcare

39. Experience from developed countries: 3. Two major approaches to achieve goals a) Demand side strategies: Efficiency  market competition  consumer choice, empowerment  consumer choice, empowerment  management of “wellness”  management of “wellness” b) Supply side strategies: Universal coverage & equal access- Universal coverage & equal access-  general tax  compulsory social insurance  global budget or budgetary process  distribution of health resources (rural health programme). (rural health programme). Restructuring Malaysia’s Healthcare System

40. Experience from developed countries: Controlling health expenditures while providing universal coverage & equal access have not been achieved through market mechanisms. Restructuring Malaysia’s Healthcare System

41. Experience from developed countries:  Some types of healthcare systems are more successful in achieving various healthcare policy goals  Consider those that can meet Malaysia’s healthcare policy goals  Consistent with:  Vision 2020  Vision for health  Vision for health  Telehealth blueprint,  Telehealth blueprint, 8 goals of the healthcare system 8 goals of the healthcare system  One-tier healthcare system  One-tier healthcare system Implications: predictive genetics Implications: predictive genetics human genome. human genome. Restructuring Malaysia’s Healthcare System

42. Role of government:  Funding  Allocation & use of resources  Conduct of process to set global budget (e.g. negotiation with providers, etc) (e.g. negotiation with providers, etc)  Ensure universal coverage (e.g. programme for rural coverage) (e.g. programme for rural coverage)  Develop & enforce policies Capital, facilities, Capital, facilities, manpower distribution manpower distribution payment payment Restructuring Malaysia’s Healthcare System Servicedistribution

43.  Universal coverage, equal access  Health Fund General tax, social insurance contribution  One-tier health system  One channel payment system  Global budget  Indirect provision - optimise use of public & private sectors private sectors  Integrated services Restructuring Malaysia’s Healthcare System Health Fund: govt-owned govt-owned non-profit non-profit Network of public healthcare services: govt-owned govt-owned non-profit non-profit entity entity In line with Telehealth blueprint

44. Thank You