Universal Health Coverage in

Malaysia – Issues and Challenges

Ng Chiu Wan, Noran Naqiah Mohd Hairi, Ng Chirk Jenn,
Adeeba Kamarulzaman

Faculty of Medicine,
University of Malaya
Background
 Socioeconomic development in Malaysia, over the past few decades, has
brought about significant improvement in the general health status of the
population partly due to sustained investment into social infrastructure such
as schools and health facilities.

 The country’s public healthcare system has been gradually improved upon
and now has wide geographical coverage and provides comprehensive care
at minimal fees to the country’s citizens.

 As a result, Malaysia can lay claim to have achieved universal health

coverage (UHC), the ultimate health system goal and one of the forerunning
contenders for a global development health goal post-2015.

2
Background
 However, the Malaysian health landscape is changing rapidly. Despite
progressive upgrading of the public healthcare system, demand for private
care has increased over the years leading to rapid expansion of the private
healthcare sector.

 Private sector development has been the result of many factors including
 efforts by the government to increase private participation in the country’s economy among
others to reduce presence of the government in the economy and also to lower the level and
scope of public spending
 the1997 Asian financial crisis which saw health tourism being promoted as a means of survival
for existing private hospitals and later as a means of bringing in foreign revenue to the country
 higher demand for private care from the increasingly affluent and discerning society

 Private sector expansion has affected provision of public care

 Perception of poorer quality of care in the public sector
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Evolution of public health system
 In the early years, public care was provided from the few public
hospitals and clinics located in larger towns
 Gradual expansion of system from the 1950’s
 Organised rural health services started after WWII
 3-tier system of a district health centre (for every 50,000 persons),
supported by subdistrict health centre (every 10,000 persons) and midwife
clinic (every 2,000 persons)
 In 2012, public network included
 147 public hospitals and special medical institutions with 42,707 beds
 3,034 static health clinics

4
Improvement in health status, Malaysia 1957 - 2010

Note: 1Until 1990, refers to life expectancies at birth for Peninsular Malaysia only. 2In constant 2005 prices. NA=not available
Source: DEPARTMENT OF STATISTICS MALAYSIA 2013. Malaysian Economic Statistics Time Series 2013, Putrajaya, Department of Statistics,
Malaysia.

5
Selected health indicators, 2012

Note:1Maternal mortality ratio for year 2013

Source: WORLD HEALTH ORGANIZATION 2014. World Health Statistics 2014. Geneva: World Health Organization.

6
Evolution of private health sector
 Early private providers were mainly clinics in urban areas and
traditional health care providers
 Rapid development started in 1980’s especially in hospital sector
 50 hospitals with 1,171 beds or 5.8% of total hospital beds in 1980
 209 hospitals with 13,667 beds or 32.0% of total hospital beds in 2012
 Mainly for-profit institutions
 Concentrated in densely populated urban areas
 Perception of higher quality of care
 Distributions of certain advanced medical equipment and specialist doctors
 Shorter waiting times for treatment

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 Increasing use of private care

Source: HEALTH POLICY RESEARCH ASSOCIATES, INSITUTE FOR HEALTH SYSTEMS RESEARCH & INSITUTE FOR HEALTH POLICY 2013. Malaysia Health Care
Demand Analysis. Inequalities in Healthcare Demand & Simulation of Trends and Impact of Potential Changes in Healthcare Spending. Kuala Lumpur: Institute for Health 8
Systems Research.
 Paying for private care

25.0 45.0%
Real health expenditures (billion 2010

OOP as % of total health expenditures

40.0%
20.0 35.0%  Fees for private care
15.0
30.0% higher than public
25.0%
care
RM)

20.0%
10.0  Paid for mainly
15.0%

10.0%
through out-of-pocket
5.0
5.0%
(OOP) payments
0.0 0.0%  Currently OOP
1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011
payments make up a
Public sources third of total health
Private sources
OOP payments as % of total health expenditures
expenditures
Source: MINISTRY OF HEALTH MALAYSIA 2013. Malaysia National Health Accounts. Health
Expenditure Report (1997-2011). Putrajaya: Ministry of Health, Malaysia.
9
Equity concerns of OOP payments
 OOP payments for health are the least equitable manner of
financing health care
 lack pre-payment and fund pooling features
 necessitate that the ill have sufficient money on hand at the point of needing care or
else they may have to forgo needed care.

 Household welfare, especially for the poor, may be affected

in the short or long-term or both since OOP payments
 can lead to immediate reduction in resources for other goods and services, including
essential items such as food and housing
 borrowings and sales of economically productive assets can also affect long-term
household welfare.

 Reliance on OOP payments for health can jeopardise UHC 10

UNIVERSAL HEALTH
COVERAGE IN MALAYSIA
- A FACT OR A MYTH
11
Universal Health Coverage
 Universal health coverage (UHC) means
 entire population has access to needed health services which are of
sufficient quality to be effective, while also ensuring that people do not
suffer financial hardship when paying for these services

 Consists of 2 essential components

 Universal access to effective health care
 Financial risk protection for health

 Assessing achievement of UHC

 Based on entitlement to universal care by law
 Based on achievement of goals of UHC

12
Source:STUCKLER, D., FEIGL, A. B., BASU, S. & MCKEE, M. 2010. The political economy of universal health coverage. Geneva: World
Health Organization.
13
 Access to needed care
 UHC requires that the entire population receives health
care that the people need
 Different assessment frameworks have been used
 Examination of tracer indicators e.g. Immunisation rates
 Overall health care utilisation rates
 Health care utilisation rates standardised for needs

14
Source: MINISTRY OF HEALTH MALAYSIA 2013. Health Facts 2013.
15
 Utilisation of care

 In 2011, there were

 4 outpatient visits per
person
 86 hospital admissions
per 1,000 persons
 Equal utilisation
across all SES groups
 Poor households used
more public services

Source: HEALTH POLICY RESEARCH ASSOCIATES, INSITUTE FOR HEALTH SYSTEMS RESEARCH & INSITUTE FOR HEALTH POLICY 2013.
Malaysia Health Care Demand Analysis. Inequalities in Healthcare Demand & Simulation of Trends and Impact of Potential Changes in Healthcare Spending. Kuala 16
Lumpur: Institute for Health Systems Research.
 Hospital admissions

Outpatient visits

Source: HEALTH POLICY RESEARCH ASSOCIATES,

INSITUTE FOR HEALTH SYSTEMS RESEARCH & INSITUTE
FOR HEALTH POLICY 2013.
Malaysia Health Care Demand Analysis. Inequalities in
Healthcare Demand & Simulation of Trends and Impact of
Potential Changes in Healthcare Spending. Kuala Lumpur:
Institute for Health Systems Research.
17
 Utilisation of needed care
 Health care utilisation
 After taking into consideration health needs, utilisation of health care
services between the rich and the poor did not differ significantly

Horizontal Inequity Index

Type of services
1996 2006

0.060 -0.007
Note.
Outpatient Visits Health needs measured using a multi-morbidity index
(0.031 – 0.088) (-0.048 – 0.034) combining reported acute and chronic conditions.
Examination of distribution restricted to those 30 years and
above.
0.017 0.032 Horizontal Inequity Index essentially measures residual
income related inequity in health care use after
Hospital Admissions standardization against health needs. Negative (positive)
(-0.020 – 0.054) (-0.012 – 0.077) values indicate pro-poor (pro-rich) distributions.

*Numbers in parentheses refer to 95% confidence intervals

Source: preliminary analysis by Mohd Ridzwan Shahari and Ng CW 18

 Financial risk protection for health
 UHC requires that the entire population be protected from
undue financial hardship as a result of health payments
 Households should not need to incur payments that are so high as to be
considered catastrophic to their welfare and which may impoverish them

 Focused on OOP payment component

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Private sources of health financing
14.00 45.00%
Real health expenditures (billion 2010 RM)

40.00%

OOP payments as % of total health expenditures

12.00

35.00%
10.00
30.00%

8.00 25.00%

6.00 20.00%

15.00%
4.00
10.00%

2.00
5.00%

0.00 0.00%
1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011
Household OOP payments Private health insurance
Private Corporations Others
OOP payments as % of total health expenditures

Source: MINISTRY OF HEALTH MALAYSIA 2013. Malaysia National Health Accounts. Health
Expenditure Report (1997-2011). Putrajaya: Ministry of Health, Malaysia. 20
Financial risk protection for health
 Low population levels incurring catastrophic health payments and those
incurring catastrophic payments were concentrated among the rich

Catastrophic Headcounts 1993 1998 2004

Note.
Headcount (%) 1.98 1.95 1.44
Catastrophic threshold used is 10% of
household consumption.
(1.74-2.23) (1.64-2.27) (1.13-1.76) Headcounts expressed as % of population.
Rank-weighted headcounts are headcounts
Rank-weighted Headcount 1.29 1.32 1.04 weighted by rank in distribution by consumption.

*Numbers in parentheses refer to 95% confidence intervals

 Levels of medical impoverishment are low, mainly affecting those who were
already poor or near poor
1993 1998 2004

Poverty headcount (%) 0.24 0.35 0.12

(0.14-0.34) (0.19-0.50) (0.02-0.21) Note.

Analysis used national poverty lines
Number of individuals 40,392 60,660 29,318 Headcounts expressed as % of population. 21
*Numbers in parentheses refer to 95% confidence intervals
 Expenditure shares for categories of
goods and services
 OOP payments for
HES 2004/05 20.1% 22.0% 21.4% 17.6%
health care a small
component of overall
HES 1998/99 22.6% 22.2% 17.5% 19.0%
household expenses
 Less than 2%
HES 1993/94 23.8% 21.1% 16.6% 18.6%
 Many households did not
0% 20% 40% 60% 80% 100% report any health
Food and Non-alcoholic beverages
Alcoholic Beverages and Tobacco
payments
Clothing and Footwear  More than a third of all
Housing, Water, Electricity, Gas and Other Fuels households in all surveys
Furnishings, Household Equipment and Routine Household Maintenance
Health
Transport and Communications
Recreation Services, Education and Entertainment
Miscellaneous Goods and Services
22
 Distribution of OOP payments

 OOP payments
concentrated among
the rich
 Predominantly used
for purchase of
private care

Source: HEALTH POLICY RESEARCH ASSOCIATES, INSITUTE FOR HEALTH SYSTEMS RESEARCH & INSITUTE FOR HEALTH POLICY 2013.
Malaysia Health Care Demand Analysis. Inequalities in Healthcare Demand & Simulation of Trends and Impact of Potential Changes in Healthcare Spending. Kuala 23
Lumpur: Institute for Health Systems Research.
 Universal Health Coverage
 Thus far, despite increasing demand for private care and
expansion of private health sector, evidence suggests that
Malaysia has achieved UHC
 Access to needed care
 Good financial risk protection for health

 However, demographic and epidemiologic changes in the

country may pose challenges to the maintenance of UHC

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UNIVERSAL HEALTH
COVERAGE IN MALAYSIA
- CHALLENGES
25
Ageing Population

Source: DEPARTMENT OF STATISTICS MALAYSIA 2012. Population Projections. Malaysia. 2010-2040. Putrajaya: Department of Statistics, Malaysia.

26
 Impact on health care utilisation

Source: HEALTH POLICY RESEARCH ASSOCIATES, INSITUTE FOR HEALTH SYSTEMS RESEARCH & INSITUTE FOR HEALTH POLICY 2013. Malaysia Health Care
Demand Analysis. Inequalities in Healthcare Demand & Simulation of Trends and Impact of Potential Changes in Healthcare Spending. Kuala Lumpur: Institute for Health 27
Systems Research.
 Epidemiologic Transition

 Pattern of diseases
changing from
communicable to non-
communicable diseases
 Many are related to
adoption of unhealthy
lifestyles
 In 2012, mortality rates
for non-communicable
diseases are about five
Source: WORLD HEALTH ORGANIZATION 2014. World Health Statistics 2014. Geneva: World
times the rates for
Health Organization. communicable diseases

28
 Self-reported chronic illness, 2011
Strokes Arthritis

Source: HEALTH POLICY RESEARCH ASSOCIATES, INSITUTE FOR HEALTH SYSTEMS RESEARCH & INSITUTE FOR HEALTH POLICY 2013. Malaysia Health Care
Demand Analysis. Inequalities in Healthcare Demand & Simulation of Trends and Impact of Potential Changes in Healthcare Spending. Kuala Lumpur: Institute for Health 29
Systems Research.
 Changes in DALYS, 1990 - 2010

Source: INSTITUTE FOR HEALTH METRICS AND EVALUATION. 2013. Global Burden of Disease Profile for Malaysia. Seattle, Washington: IHME. 30
 Changes in mortality rates, 1990 - 2010
 mortality rates had
decreased for all age
groups except for males
aged between 25 and 44
years
 largest increase was for
males aged between 35
and 39 years
 largest contributor to this
mortality increase was from
HIV/AIDS
 In 1990, 11% of all deaths
among males aged 35 to 39
years was caused by
HIV/AIDS and this
increased to 33% in 2010
Source: INSTITUTE FOR HEALTH METRICS AND EVALUATION. 2013. Global Burden of Disease
Profile for Malaysia. Seattle, Washington: IHME. 31
Impact on UHC

 To maintain UHC, the public healthcare system will need to

increase its capacity to meet increasing health care needs
 Some indications that the public system is already
overloaded
 cases of patients by-passing public facilities for private facilities due to long waiting
times
 poor availability of essential medicines in public hospitals leading to the need for
patients to purchase from private pharmacies

 If public system is unable to cope, patients

may be increasingly
compelled to purchase higher priced private care even at
the risk of exposing themselves to financial catastrophe
and thus jeopardise UHC 32
 Household OOP payments by
expenditure categories, 2009

Source: HEALTH POLICY RESEARCH ASSOCIATES, INSITUTE FOR HEALTH SYSTEMS RESEARCH & INSITUTE FOR HEALTH POLICY 2013. Malaysia Health Care
Demand Analysis. Inequalities in Healthcare Demand & Simulation of Trends and Impact of Potential Changes in Healthcare Spending. Kuala Lumpur: Institute for Health
Systems Research. 33
 Gaps in diagnosis of diabetes, 2011
Known diabetics Actual diabetics
(prevalence 7.2%) (prevalence 15.2%)

Source: HEALTH POLICY RESEARCH ASSOCIATES, INSITUTE FOR HEALTH SYSTEMS RESEARCH & INSITUTE FOR HEALTH POLICY 2013. Malaysia Health Care
Demand Analysis. Inequalities in Healthcare Demand & Simulation of Trends and Impact of Potential Changes in Healthcare Spending. Kuala Lumpur: Institute for Health 34
Systems Research.
Coverage of ART, 2013

Source:MINISTRY OF HEALTH MALAYSIA 2014. Country response to HIV/AIDS. Malaysia 2014. Putrajaya: Ministry of Health, Malaysia.
35
SUSTAINING UNIVERSAL
HEALTH COVERAGE IN
MALAYSIA
36
Health system changes
 The Malaysian public healthcare system has been credited to have brought
about UHC in the country.
 However, the system’s capacity to cope, in the face of an ageing society with its double burden of
communicable and non-communicable diseases, has been called to question.

 The country would need to invest more into the public system than is currently
the case.
 In 2011, public sources of financing made up only 2.25% of GDP or 6.62% of general
government expenditures

 The 10th Malaysia Plan included a call for greater development of the private
health sector, albeit as an avenue for enhanced national economic growth, and
that there should be “greater collaboration between the public and private
healthcare systems to allow effective delivery, greater efficiency and affordable
costs” with an element of cost-sharing between patients and the government.
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Health system reforms
 With higher fees in the private sector, this would effectively translate to a dual
healthcare system
 a public health system which provides lower quality care for the poor and a better quality private
health system catering mainly to the demands of the rich

 The crux of the issue here is the question of what should be included in the
package of health care services which is understood to be the entitlement of all
in Malaysia under UHC.
 If it can be shown that the public healthcare system has indeed made such a package universally
available then it can be argued that this two-tier system will not compromise UHC since the
private system is merely providing services that are over and above the agreed upon minimum
package already available to all.
 This package has not really been openly debated in Malaysia.

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Health system reforms
 This public debate should also include discussion of acceptable balance
between public and private provision of care in Malaysia
 development of these two sectors may not progress in a synergistic manner.

 If a health system dominated by private sector providers is deemed socially

acceptable, then there are some merits to the recommendation of a social
health insurance system for Malaysia as an additional health funding source
and to supplement and strengthen existing regulation of the private sector.

 At this point in time it is not certain whether the proposed social health
insurance scheme would prove to be more equitable than the current taxation-
based one as this is heavily dependent on the contribution rates, co-payments
and benefit entitlements which have not been released.

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CONCLUSION

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Conclusion
 Malaysia is a country where UHC has achieved through an extensive public
healthcare system providing near-free comprehensive health care financed
through general taxation

 This public system is facing challenges partially arising from demographic and
epidemiological changes in the country and partially from the expansion of
private provision of care. In spite of this, current evidence points to the
continued maintenance of UHC in Malaysia

 Nonetheless, unabated expansion of the private health sector has the potential
to adversely affect universal access to care due to several inherent
characteristics in the provision of private health care including
 high user fees
 mal-distribution of private facilities favouring affluent urban areas

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Conclusion
 These unwanted effects may be accentuated in the coming years by socio-
demographic changes in the country specifically by the ageing of the population
and adoption of unhealthy lifestyles.

 Further improvement of the public system and maintenance of universal access

to health care in the country will require public debate and consensus as to the
future structure and organisation of the country’s healthcare system.

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THANK YOU

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