3.1 Human Development and Health

Malaysia’s health development has been part of the wider process of human and other socio-economic progression. This chapter provides the broader context to the Malaysian health system through a brief analysis of socio-economic development and its impact on health risks and conditions. There were also associated health improvements that in turn fostered human development. This analysis provides a macro and concise framework for the more detailed examination in other chapters of the development of the Malaysian health system in terms of its service delivery, related inputs and more detailed outcomes.

Malaysians have made noteworthy socio-economic progress since the country’s independence in 1957, in view of the advantages and challenges of their physical and equatorial environment. As a result of these efforts, Malaysia is now among the countries that have achieved very high human development according to the United Nations Development Programme (UNDP), based on attained life expectancy, education and income per capita (United Nations Development Programme, 2018). Malaysia is also among the group of high- to middle-income countries with a gross national income per capita of $26,190 in 2015 (purchasing power parities, 2015), compared with the substantially lower average of $15,627 for countries in the same income group (World Bank, 2017), and is on the pathway to joining the high-income group of nations.

Malaysia is a good example of a comprehensive approach to development. Since independence, government policies have been progressively articulated in five-year development plans in a holistic manner that deals not only with the economic elements but also other social elements of human development, including health. Thus health interventions are planned and implemented in the context of a range of complementary activities in socio-economic development. They reflect priorities set across the board, including labour force and financial resource constraints, and the steps taken to address them. Therefore, it is essential to examine health advances in conjunction with concurrent socio-economic development that affects the way people live and where, and what they do, with an impact on social organisation, as well as geographical and financial factors that have a bearing on relative access to health services and living conditions.

The progress made in human development in Malaysia has been substantial in terms of the three measures used by the UNDP in its index of human development: life expectancy, education and gross domestic product (GDP) per capita. Using 1970 as a basis, life expectancy had increased by 11 years to 75.6 years in 2015, secondary education enrolment more than doubled to 85%, and GDP per capita increased by more than five times to 35,100 Malaysian Ringgit (Table 3.1).

Three major phases can be identified in human development since independence. Their expression in health development is as follows:

• The first phase, during the 1960s and 1970s, emphasised rural development and capacity building of the health system.

• The second phase, in the 1980s and 1990s, was one of consolidating socio-economic transformation and the health system, from a rural setting to rising employment in secondary industries, urbanisation with migration from rural to urban centres and growing health system capacity.

• The third phase, in the 2000s and 2010s, has the characteristics of a more developed socio-economic configuration, with growing urbanisation and sustained employment in manufacturing but a larger proportion of people employed in services. Conditions have continued to improve, but growing affluence and more sedentary occupational and recreational activities have led to lifestyles that compromise the rate of health enhancements.

Health status has been closely associated with poverty, and in turn, health services provision has contributed to poverty alleviation (Reference Hammer, Nabi, Cercone, van de Walle and NeadHammer et al., 1995). In addition to socio-economic factors in development during the above three phases, four variables will be used in the analysis to examine the evolution that affected health status in Malaysia: poverty prevalence for social and economic security affecting health status; urban/rural residence for the manner of social organisation and geographical access to health services; rate of safe deliveries for access to and coverage by basic health services; and infant mortality rates as a marker of health status in a relatively young society, even today.¹

3.2 Reaching the Poor in Rural Malaysia and Increasing Capacity (1960s and 1970s)

At independence in 1957, about three-quarters of Malaysians lived in rural areas (74%), and close to half of the labour force worked in agriculture (47%), mostly in rubber plantations and rice cultivation. The unemployment rate was estimated at 13%, but it was posited that there was considerable additional disguised unemployment (Reference Fernandez, Hawley and PredezaFernandez et al., 1975; Reference JonesJones, n.d.; Supplementary Table 3.J). Poverty was pervasive, with 51% living below the poverty line on average and 60% living in rural areas (Reference RoslanRoslan, 2001; Supplementary Table 3.D). This was associated with a high population growth rate (almost 3% per year) driven by a high fertility rate of more than 5 live births per woman, which led to a large proportion of the population being under 15 years of age (44%) and a dependency rate of 82% on the working-age population but a relatively low proportion of people aged 65 years and over (3%). However, the high rate of infant mortality (75/1,000 live births) contributed to low life expectancy at birth of only 57 years at that time (Reference Fernandez, Hawley and PredezaFernandez et al., 1975; Supplementary Tables 3.E, 3.H and 3.I). In addition, poor health due to the high incidence of malaria, tuberculosis and other communicable diseases (Reference RoemerRoemer, 1976) affected the productivity of human capital. There is also evidence of malnutrition in children from poor rural areas (Reference McKay, Lim, Notaney and DugdaleMcKay et al., 1971; Reference Chong, Tee, Ng, Kandiah, Hussein, Teo and ShahidChong et al., 1984). The low level of education was another dimension of the quality of human capital: in 1957, more than half the population aged over 14 years (53%) were illiterate in any language (Ministry of Education Malaysia, 1967), with implications for female fertility and maternal and child health associated with the level of education of women.

Few doctors and nurses were concentrated in urban centres in relation to the population (Supplementary Tables 3.K and 3.L) to address the large burden of disease and mortality. There was significant reliance on traditional healers, with services provided by bomohs (healers) and kampong bidans (village midwives) in the Malay tradition. Sinsehs (Chinese physicians) provided herbs and other traditional Chinese medicines, supplemented on occasion by Western-type medicines. There were also a few Ayurvedic practitioners from India. It was not uncommon for care to be sought interchangeably regardless of ethnicity. Although there were reservations about the effectiveness of traditional practices, the household expenditure survey for 1957/1958 indicated that households spent almost as much on traditional medicines with a lower price as they did on more costly Western ones (Reference RoemerRoemer, 1976).

It was in this context that various Malaya and Malaysian² plans were formulated to address both economic and social development during this first phase. Rural development became a major policy objective in the 1950s and 1960s to address the productivity, income and living conditions of most people in Malaysia. Government development expenditure rose from 3.6% of the GDP in 1956–1960 to 6.8% in 1966–1970 and government revenue from the export of oil rose to 12.6% of the GDP in 1976–1980 (Reference Lee and Chew-GingLee & Chew-Ging, 2017). During 1956–1980, about a third of development expenditure was for infrastructure such as roads, power and communication that enhanced rural and regional transport and communication, and about one-quarter was for agriculture to improve productivity and the income of poor rural populations engaged in rice cultivation, reforming rubber plantations and developing palm oil cultivation in small holdings with improved productivity. A substantial development expenditure that included security (due in part to internal emergency and confrontation with Indonesia over the sovereignty of Sabah and Sarawak) absorbed some 16% of the total government development expenditure during this period. Development expenditure on education and health (which tends to be less than that on security, transport and public works) amounted respectively to about 8% and 2% of the total during this period (Reference PeacockPeacock, 1981; Reference FongFong, 1985; Reference Aslam and HassanAslam & Hassan, 2003).

The importance of health services reaching the poor in rural areas was expressed in the priority given to the following complementary activities (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.):

• Training of health personnel and recruitment in rural areas.

• Provision of rural health services, including safe water and sanitation.

• Prevention and management of communicable diseases.

• Improved hospital capacity to support primary care.

• Family planning and nutrition supplementation.

This reflected the considerable regional differences in infant mortality that prevailed through the 1960s and 1970s, which were associated with the proportion of people living in rural areas and with levels of household poverty. Accordingly, the state of Terengganu, with 68% of households living in poverty and 73% of its population in rural areas, had an infant mortality rate of 54 per 1,000 live births; Selangor, including Kuala Lumpur (Malaysia’s large urban capital), had a lower proportion of rural population (55%), a lower level of poverty (43%) and a substantially lower infant mortality rate of 30 per 1,000 live births (Reference HasanHasan, 1986).

The efforts made to improve economic productivity resulted in an average GDP annual growth rate of 7.1% in the 20-year period of 1960–1980. However, the large population growth reduced it to a still-helpful rate of 3.7% per head of population (Supplementary Tables 3.A and 3.E). Even though primary industries continued to constitute a large proportion of the GDP (31%) in 1980, the proportion of secondary production almost doubled to 25% of the GDP, with little change in the proportion of services (44%) (Supplementary Table 3.B). Employment saw a substantial decline in the proportion of the population employed in primary industries, mostly in rural areas, from 50% to 39% during the 20-year period and an increase in the proportion of those employed in services from 30% to 40% (Supplementary Table 3.C). Although the majority of the population continued to live in rural areas, greater urbanisation took place, and the proportion of the population living in urban areas increased from 26% in 1960 to 42% in 1980 (Supplementary Table 3.J), with consequences for the mode of living, type of work and conditions and relative ease of access to health services. Further, substantial gains were made in education. By 1967, enrolment among children of relevant age in primary education had risen to 94% and to 52% in lower secondary education, with considerable progress in the education levels of women (Ministry of Education Malaysia, 1967), which is associated with fertility and maternal and child health (Reference HasanHasan, 1986). This was coupled with the increase in the female labour force participation rate from 37% in 1970 to 44% in 1980 and the observed substantial decline in fertility, which was also enhanced by the family planning programme in 1965 (Reference Fernandez, Hawley and PredezaFernandez et al., 1975; World Bank, 2019d; Supplementary Table 3.G).

Development in terms of personnel and rural health facilities made substantial progress during this phase. The number of people per nurse declined about four-fold and that per doctor declined by about half during the 20-year period of 1960–1980 (Supplementary Tables 3.K and 3.L; Chapter 8). Public hospital services were upgraded without an increase in the number of beds per head of population, but their use rose by 43% during the same period (Chapter 5). The proportion of the population served by sewerage rose by about 89% and that with access to safe water increased by about 82% in the 10-year period 1970–1980 (World Bank, n.d.; Chapter 7). The impact on health of the various preventive and management interventions is illustrated by the 29% decline in the incidence of malaria and 96% decrease in the incidence rate of diphtheria in the 4-year period of 1976–1980 (Chapter 6). This progress was achieved with a relatively low total health expenditure. Estimates for 1973 indicated that total health expenditure amounted to only about 2% of the GDP, and that 65% of it was spent in the public sector (Reference RoemerRoemer, 1985; Chapter 8).

During 1960–1980, socio-economic development and changed employment opportunities increased the proportion of the urban population from 26% to 42% in 1980, and poverty levels declined from 49% in 1970 to 37% in 1980. Easier access to health services and increased service provision in rural areas led to greater health services coverage. In Peninsular Malaysia, safe deliveries by professionally trained health personnel rose from 41% to 85% during this 20-year period; as a proxy measure of health improvement in a young population, the infant mortality rate declined by more than half from 69 per 1,000 live births in 1960 to 24 in 1980 (Table 3.2). Life expectancy at birth rose by 8 years to 68 years in that period (Supplementary Table 3.G).

3.3 Transition and Consolidation (1980s and 1990s)

The core development objectives in the 1980s and 1990s were the eradication of poverty, the re-structuring of society and more balanced regional development (Prime Minister’s Department, 1989). The related health policy goals set out in the Fourth to Seventh Malaysia Development Plans were (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.):

• Training of health personnel and their engagement to serve the growing population and a better mix of human resources to provide needed services.

• Reduction in the disparity of health status among different population groups and areas.

• Control of preventable infectious diseases.

• Promotion of healthy living environment.

• Collaboration in health promotion between the public and private sectors and among agencies.

• Improvement in productivity and quality of services.

A major transition took place in Malaysia during these two decades. The population almost doubled from about 14 million to 23 million (Supplementary Table 3.E) in spite of a decline in the average fertility from four to three children per woman (Supplementary Table 3.G). Consequently, the proportion of children aged under 15 years decreased, with a compensating increase in the proportion of working-age people (15–64 years), which reduced child dependency on working-age people from about 70% to 53%, but the proportion of older people aged over 64 years remained low at 4% (Supplementary Tables 3.H and 3.I). The growth in working-age people was accompanied by a major shift in economic activity from agriculture to manufacturing and related employment. Accordingly, employment in primary industries, mostly agriculture, declined from 39% in 1980 to 16% in 2000, and the proportion of people employed in secondary industries (manufacturing and construction) rose from 21% to 36% (Supplementary Table 3.C). The economic transformation provided a wider range of employment opportunities, and the unemployment rate, which had risen to 8% in 1987 (Department of Statistics Malaysia, 1989), fell to 3% in 2000 (Department of Statistics Malaysia, 2001a). Income rose faster than the large growth in population and led to a substantial increase in GDP per head of population at an average annual rate of 3.7% during that period (Supplementary Table 3.A).

However, the rate of progress was upset by the oil crisis in 1979, which affected government revenue and led to fiscal constraints in the 1980s and an economic recession in 1985–1986. Government development expenditure that was still substantially high at 11% of the GDP in 1981–1985 dropped to 6% by 1996–2000 (Reference Lee and Chew-GingLee & Chew-Ging, 2017). As the emphasis on development moved to manufacturing, government development expenditure on agriculture was reduced by about half to 12% of the total in 1981–2000, while investments in infrastructure for roads, communication and power generation continued to receive about one-third (34%) of the total, and investments in industry increased somewhat from 14% to 17%. Government recognition of the importance of the continual improvement of human capital for both economic and social purposes was shown in the rise of development expenditure on education from 8% to 12% and that on health from 2% to 3% (Reference Aslam and HassanAslam & Hassan, 2003). Primary education enrolments became almost universal (97%); secondary school enrolments rose to 65% and that in tertiary education to 26%, with female enrolments, of particular importance to health, being at least on a par with that of men (United Nations Educational, Scientific and Cultural Organization, 2011).

Another aspect of the socio-economic transformation was internal migration to urban areas with employment opportunities. A study carried out in 1989–1990 (Department of Statistics Malaysia, n.d.) indicated that the more rural states lost some of their population due to internal migration, while the more industrialised states gained population that way. As might be expected, internal migrants, both male and female, were younger, and with a higher level of secondary and tertiary education. The majority were Malays from rural areas. By 2000, most people lived in urban areas (Supplementary Table 3.J).

These major socio-economic shifts involved a number of inter-related features that affected population composition and altered health risks. The larger urban population employed in manufacturing and services and the greater participation of better-educated women in the labour force were associated with lower fertility and a rise in the proportion of people of working age, with lower levels of unemployment, higher household income and less poverty. However, occupations required less physical activity, while food intake was enhanced by higher household income and less poverty. As the socio-economic transformation took hold, demographic and epidemiological transitions took place. The epidemiological transition was expressed in terms of a decline in the burden of disease from infectious diseases because of the success of related health interventions, but non-communicable diseases increased with occupational and leisure activities and greater affluence, with an effect on health risks, health conditions and mortality (Table 3.3).

Access to medical services improved during the two decades of 1980–2000 as the number of people per doctor declined by more than half (Supplementary Table 3.K; Chapter 8). The number of nurses and midwives rose in relation to the population, but the number of assistant nurses declined (Supplementary Table 3.L; Chapter 8). Vaccination of infants for a range of communicable diseases reached over 90% coverage in most cases (Chapter 4). Rural household sanitation rose to 98% and access to safe water to 94% (Ministry of Health Malaysia, 2002; Chapter 7). The rise in urbanisation and higher household incomes made access to private health services easier. This was associated with an increase in the proportion of doctors in the private sector (46%) (Ministry of Health Malaysia, 2002) and almost double the number of people employed in private hospitals and maternity homes (Department of Statistics Malaysia, 2001b). This meant that the rate of both outpatient visits and inpatient admissions to public hospitals per head of population either stayed about the same or declined slightly (Ministry of Health Malaysia, 1992; 2002). The transition is reflected in the estimated proportion of visits to doctors that might have been about equal between the public and private sectors in the 1980s but might have been higher in the private sector in the 1990s (Health Policy Research Associates et al., 2013). The rising use of the private sector had an impact on the level of health expenditure in relation to the GDP. A study of health financing indicated that total health expenditure in 1983 amounted to 2.8% of the GDP and that 76% was related to services provided by the public sector (Westinghouse Health Systems, 1985), while estimates for 2000 show that total health expenditure was 3.3% of the GDP and that 54% was financed by the public sector (Ministry of Health Malaysia, 2017; Chapter 8). This indicates that the rise in total health expenditure in relation to the GDP in that period might have been mostly from the growth in the private sector.

The socio-economic transformation during 1980–2000, with increasing employment opportunities and migration to urban areas, resulted in most people living in urban areas. It also led to a dramatic drop in the proportion of households living in poverty, from 37% in 1980 to 9% in 2000. Empirical evidence shows that, in addition to its direct impact on health status, the provision of health services by the public sector had considerable distributional effects on alleviating poverty in Malaysia (Reference Hammer, Nabi, Cercone, van de Walle and NeadHammer et al., 1995). Greater coverage of and access to healthcare was facilitated by urbanisation and services rendered by both the public and private sector and the greater use of preventive and other services in the public sector. This was reflected in the increase in the proportion of safe deliveries by health professionals to 97% in 2000. Infant mortality at 7 per 1,000 live births in 2000 had declined to about one-third of that in 1980 (Table 3.4); life expectancy continued to rise by 5 years to 73 years in 2000 (Supplementary Table 3.G).

Progress was also made in narrowing the differences between regions, although the differences prevailed. Kelantan, with a high proportion of its population living in rural areas (66%), had the highest infant mortality rate in Peninsular Malaysia, being about twice that of Selangor in 2000 (Table 3.5). However, the difference had been almost three times higher in 1980 (Suleiman & Jegathesan, n.d.).

3.4 Health in a More Affluent and Urban Society (2000s and 2010s)

The steered socio-economic transformation of Malaysia has led to a more affluent and increasingly urban society. Globalisation of the economy is nothing new to Malaysians. At independence, Malaysia was substantially dependent on rubber and tin production for global markets. Its economy evolved as global markets for different commodities changed to the production of palm oil and crude oil and the manufacture of electronic components and products, again mostly for global markets. Thus Malaysia felt the effects of both the Asian financial crisis in the late 1990s and the impact of the global financial crisis in the mid-2000s. Economic growth that faltered in the late 1990s to the mid-2000s regained its strength after 2010, and the GDP per head of population grew at an annual rate of 3.5% in 2010–2017 compared with 2.6% in 2000–2010 (Supplementary Table 3.A).

The Malaysian economy has the features of more developed countries, with a decline in the proportion of the GDP from primary industries, a continuing large contribution from secondary industries and more than half of total production from services (Reference Martins, Guo and SwansonMartins et al., 2018), with similar employment patterns. By 2017, 62% of people employed worked in services, 26% worked in manufacturing and construction and 12% worked in primary industries, mostly in agriculture (Supplementary Tables 3.B and 3.C). The larger proportion of employment in secondary and tertiary industries and the decline in agriculture were associated with the growth of urbanisation to 75% in 2017 (Supplementary Table 3.J).

The importance of training and education to economic activity is reflected in the high level of education of people employed in 2016: no formal education, 3%; primary education, 15%; secondary education, 55%; and tertiary education, 27% (Department of Statistics Malaysia, 2017a). In 2017, the net enrolment of people of relevant age in primary education was 99% (female, 99%); secondary education, 75% (female, 78%); and tertiary education, 75% (female, 78%) (Ministry of Education, 2018). The labour force participation rate of working-age people increased to 68% in 2017, with female participation rising to 55% (Department of Statistics Malaysia, 2017a; 2018a). The unemployment rate rose only slightly from 3.1% in 2000 to 3.4% in 2017 (Department of Statistics Malaysia, 2003b; 2018a).

The greater urbanisation, higher education levels and greater female participation in the labour force were associated with a substantial fall in fertility from above replacement level (2.8 children per woman) in 2000 to below replacement level (1.9 children per woman) in 2017. Population growth continued to be high due to the large proportion of young people of reproductive age, but the rate of growth was reduced by half from an annual average of 2.6% in 2000 to 1.3% in 2017 (Supplementary Table 3.E). A feature of this continuing population growth was the increase in the proportion of people other than those identified as ethnic Bumiputra, Chinese or Indian³ from less than 1% (0.5%) of the population in 1980 to 11% in 2017, which indicated a substantial growth in immigration (Supplementary Table 3.F).

The decline in fertility led to a demographic bonus in terms of the rise in the proportion of working-age people from 63% in 2000 to 70% in 2017 and a more productive young population. In the same period, the proportion of children dropped from 33% to a still-high percentage of 24%, while the proportion of older people increased somewhat from 4% to 6% (Supplementary Table 3.H). This meant a fall in the child dependency rate on the working population from 53% in 2000 to 35%, and old age dependency rose from 6% to a still-low 9% during the same period (Supplementary Table 3.I).

Among other priorities, health priorities identified in the three Malaysia Plans covering 2001–2015 were concerned with (Economic Planning Unit, 2001; Ministry of Health Malaysia, n.d.):

• Improving accessibility to affordable and quality care and addressing inequalities.

• Expanding wellness programmes aimed at improving quality of life.

• Promoting co-ordination and collaboration between the public and private providers of healthcare.

• Increasing the supply of healthcare human resources.

• Addressing efficiency issues in healthcare delivery.

• Strengthening regulatory and enforcement function to administer the health sector.

The concern with human resources in the provision of health services was met by a substantial increase in the availability of the two major professional resources. The number of people per doctor was about halved from 2000 to 632 in 2016 (Supplementary Table 3.K), and the number of people per nurse more than halved to 308 (Supplementary Table 3.L). By 2016, an increasing proportion of the larger number of doctors were in the public sector (65% in 2015), and even more so in the case of nurses (76% in 2015) (Ministry of Health Malaysia, 2018a; Chapter 8).

Prevention of infectious diseases remained a major objective, and child vaccination coverage continued to be high (Ministry of Health Malaysia, 2018a; Chapter 4). The same was true for access to safe water and sanitation, and the incidence of malaria continued to be low (Ministry of Health Malaysia, 2018a; Chapters 6 and 7). Another achievement was the eradication of polio. However, the incidence of dengue, often associated with growing urban centres, increased considerably, but better management of those affected resulted in a decline in case fatality rates. A major concern during this period was the threat of HIV/AIDS, which reached its incidence peak in 2002. Prevention efforts led to a fall in incidence by about half in 2016. However, HIV/AIDS affected efforts to control the incidence of tuberculosis, which increased to some extent (Ministry of Health Malaysia, 2018b; Chapters 4 and 6).

Urbanisation, sedentary occupations and greater affluence are associated with a rise in health risks related to non-communicable diseases, such as obesity (Ministry of Health Malaysia, 2018b). A study of diet, physical activity and smoking, which have an impact on health risks, such as diabetes, circulatory diseases and lung cancer, indicated that cultural differences resulted in varying behaviours among ethnic groups, and the authors proposed that a more culturally targeted approach was needed for these health risks. It is noteworthy that the study found that access to healthcare also made a difference (Reference Botobara-Yap, Razon-Estrada and BalilaBotabara-Yap et al., 2017). The increasing burden of non-communicable diseases was reflected in the increasing proportion of heart and cerebrovascular diseases from 18% to 21% of all deaths from 2001 to 2017 (Department of Statistics Malaysia, 2007; 2018b). It is also manifested in the prevalence of diabetes, which increased from 12% to 15% in the 5-year period from 2006 to 2011 (Ministry of Health Malaysia, 2013; Chapter 6).

Public hospital outpatient visits increased, but their number per head of population declined, and visits to other public health clinics rose (Ministry of Health Malaysia, 2018a; Chapters 4 and 5). Evidence from household surveys indicated that the number of visits to doctors in the private sector might have been larger than the number of visits to doctors in the public sector (Health Policy Research Associates et al., 2013). Nevertheless, public sector health services remained the highest provider of both preventive and medical care. The number of people employed in private hospitals continued to grow by more than two-fold in 1999–2015 (Department of Statistics Malaysia, 2001b; 2017b), and the use of private inpatient care increased. However, admissions to public hospitals also rose substantially (Ministry of Health Malaysia, 2002; 2018a; Chapter 5). Despite the rise in private sector provision, the public sector continued to be the largest provider of inpatient as well as preventive and ambulatory medical services. It has been estimated that the above-mentioned considerably higher proportion of both preventive and curative services supplied by the public sector was financed by the public sector at only 51% of total health expenditure in 2015. The private sector, with a considerably lower proportional provision, was financed by 49% of the total health expenditure (Ministry of Health Malaysia, 2017; Chapter 9). A possible implication of this, all other things being equal, would be a considerable rise in health expenditure as a proportion of the GDP (4.6% in 2015) if all health services provided were at the expenditure per unit of service prevailing in the private sector.

Continuing economic development and employment opportunities in secondary industries, but especially in services in urban areas, continued to fuel the growth in urbanisation, which rose from 62% in 2000 to 75% in 2016. It was also associated with high levels of employment that improved social and income security further, which helped to alleviate poverty and its associated health conditions. The household poverty rate declined from 8.5% to 0.4% in 2000–2016 (Table 3.6). Although the substantial decline in poverty is not questioned, the actual levels and methodology have been queried in more recent times in view of alternative estimates (Reference RavallionRavallion, 2019). Despite caveats regarding the measurement of poverty, it is apparent that poverty has continued to decline since 1999. Infant mortality was highest in Sabah, which had the highest rate of poverty and a large proportion of its population still living in rural areas, and was lowest in urban Kuala Lumpur, which had one of the lowest levels of poverty in Malaysia (Reference Nair and SagaranNair and Sagaran, 2015; Department of Statistics Malaysia, 2013; 2016a).

As a measure of essential health service coverage and provision in a still relatively young population, safe birth deliveries by professional personnel were almost universal (99.5%) by 2016. Although fertility declined substantially, the momentum from the high proportion of people of reproductive age kept the birth rate at 16 per 1,000 people. A reflection of the need to support the larger number of childbirths is that about a third of admissions (32%) to public hospitals, which provided the most obstetric care in 2015, were related to childbirth and related conditions (Department of Statistics Malaysia, 2017a).

In contrast to previous periods, the infant mortality rate did not improve to any significant extent, remaining at about 7 per 1,000 live births during 2000–2016 (Table 3.6). This lack of improvement was also observed for maternal mortality, which remained at around 24 per 100,000 live births during the same period (Ministry of Health Malaysia, 2018b). Although not reflected in formal records of infant mortality (Department of Statistics Malaysia, 2003a; 2016a), analysis of the location of the growing number of non-citizens (10% of the total population in 2017) (Department of Statistics Malaysia, 2017c) shows that states that experienced continued improvements in infant mortality, such as Kelantan, tended to have a lower proportion of non-citizens in the population, while those with a higher proportion, such as Johor, experienced either a standstill or a worsening (Department of Statistics Malaysia, 2003a; 2016a). This raises the question of potential inaccuracies in the registration of infant deaths of non-citizens.

Notwithstanding the stagnation in the recorded trend towards lower infant and maternal mortality, an achievement was the increase in life expectancy since 1999, in spite of the threat of HIV/AIDS and risks from more sedentary occupations and affluent lifestyles: life expectancy rose by more than 2 years between 1999 and 2017 (Table 3.7).

The potential for further improvements in health status and life expectancy is suggested by studies of avoidable deaths (Ministry of Health Malaysia & Harvard T. H. Chan School of Public Health, 2016) and potential years of life lost due to premature mortality and disability (Institute of Public Health, 2017).

These studies point to the potential gains from improvements in occupations and lifestyles that affect mortality and disability from non-communicable diseases, as well as better identification and management. Injury from traffic accidents and other causes is another major area for potential gains. The importance of mental health is also apparent. The research also indicates the continuing importance of preventing and managing infectious diseases (Table 3.8).

3.5 Progress and Challenges

This chapter provides a concise and macro analysis that places salient features of health development in its socio-economic framework as a basis for the following chapters, which address the various components of the health system and their complementary contributions to health outcomes.

Health has been an integral and important part of Malaysia’s socio-economic and human development that has aimed at alleviating poverty, enriching human capital, improving living conditions and enhancing health status.

Strategies have been articulated in five-year development plans in which health development has played a vital role in conjunction with education, employment and living conditions. These strategies have evolved as the success of rural development has taken hold and economic development has provided employment opportunities in secondary industries, with growing urbanisation and an increase in related living conditions. The health system’s success in preventing and managing communicable diseases has led to an epidemiological transition that has improved health status but that has made it more dependent on the control of the non-communicable diseases characteristic of more developed, urban and affluent societies. Accordingly, progress has improved health, but it has also created new challenges to continued success in addressing the risks of infectious diseases while strategies and means of tackling the threats posed to wellbeing by the burden of non-communicable diseases are being developed.

3.6 Key Messages from Malaysia’s Experience

4.1 Introduction

The term ‘primary health care’ (PHC) has been operationalised in a variety of ways since it was first coined as part of the historic Alma Ata Declaration (Box 4.1). In this chapter, we operationally define PHC to cover the ‘first level of contact of individuals, the family and community with the national health system’ and ‘reflect(s) and evolve(s) from the economic conditions and sociocultural and political characteristics of the country’. The elements of PHC we will focus on include ‘education concerning prevailing health problems, … maternal and child health care including family planning and immunization, and appropriate treatment of common diseases and injuries’. Other aspects of PHC, such as safe water and basic sanitation, prevention and control of locally endemic diseases, and provision of essential drugs, are covered in other chapters.

This chapter explores the development of PHC during the 60-year period after Malaysia achieved independence (1957–2018). The development process is viewed in the context of the interaction of various components of the health system, as well as the interactions with other sectors and the influence of international movements. Two distinct phases of development are evident, as described in Sections 4.2 and 4.3.

4.2 The First Phase of PHC Development (1960s–1990s)

4.3 The Second Phase: The Continuing Journey towards Integrated PHC Services (1990–2017)

4.3.2 PHC Services in the Public Sector

The overarching goal of the public sector was to achieve equitable access to more comprehensive primary care. Three threads of interlinked thrusts towards this goal are discernible, namely:

• Expanding the scope of PHC services to encompass additional age groups and health needs.

• Integrating preventive-cum-promotional services with curative services to address segmentation and compartmentalisation and provide seamless care for individuals, families and communities.

• Improving the quality of services to respond better to expectations in the community and professional groups.

4.3.2.1 Expanded Scope of Preventive PHC Services in the Public Sector

During the 1990s, responding to demographic and morbidity trends, the preventive and health promotional services provided by health centres expanded to include additional age groups (adolescents, adults, women’s and workers’ health, the elderly, children with special needs) and health problems, such as mental health and screening for iodine deficiency and glucose-6-phosphate dehydrogenase (G6PD) deficiency, while the national childhood immunisation programme expanded to include measles, mumps and diphtheria, and Haemophilus influenzae (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.).

The clinic-based services were complemented by community-based programmes. The nutritional surveillance of children and pregnant women conducted in 1988 provided valuable input to the national poverty reduction initiatives and rehabilitation efforts (National Coordinating Committee on Food and Nutrition, 2006). The Food Basket Programme (also known as the rehabilitation programme for malnourished children) for children with poor nutritional gain continued to reach out to poor communities (National Coordinating Committee on Food and Nutrition, 2006). Clinic-cum-community services were also initiated to support anti-tobacco smoking efforts, which included smoking cessation clinics. The health clinic advisory panels (panel penasihat), with local community representatives, worked with health staff on four major areas: healthy ageing, advocacy for immunisation, dengue control, and diabetes and overweight management (Reference Mustapha, Omar, Mihat, Noh, Hassan and Abu BakarMustapha et al., 2014).

Simultaneously, the hitherto rural health services gradually increased their coverage to include urban areas in response to demands from local authorities that had little interest in providing services that did not generate revenue. This required organisational re-structuring, including the transfer of authority, staff and some physical facilities from the local authority to the national MoH, particularly in the metropolitan cities of Penang, Melaka and Kuala Lumpur. It also paved the way subsequently for easier integration of preventive and curative services.

Gaps in and limitations to expansion.

Financial and human resources constraints limited some of the service expansion. For example, cervical cancer screening had already been planned to incrementally cover larger sections of the target age group, but laboratories could not cope, and the turnaround time was slow. Screening reached only 6% of eligible women (aged 20–65 years) between 1996 and 2003 (Figure 4.1) (Ministry of Health Malaysia, 2005), and follow-up call services were inadequate (Reference Wong, Wong, Low, Khoo and ShuibL. P. Wong et al., 2008). Also, other components of the health system interacted with PHC services in the public sector to initiate, facilitate or limit the expansion of PHC services. Examples are summarised in Box 4.4.

Figure 4.1 Pap smear slides taken and coverage in Malaysia, 1994–2003.

Source: Ministry of Health Malaysia, 2005.

Box 4.4 Influence of other health system components on PHC: summary of illustrative examples

Examples of Limiting Factors

Finance: Dictated the speed and influenced the scope of expansion. While new programmes were added, some existing programmes, such as family planning and cervical cancer and breast cancer screening programmes, failed to gain traction.

Workforce: Upgrading the competencies and recruitment of new categories with different competencies needed, such as finance, training and managerial support. For example, the lack of trained staff hampered the ability to provide rehabilitation, occupational therapy, home visits and home care nursing services for the elderly.

Examples of Enabling Factors

Medical products and technology: Additional affordable vaccines (measles, mumps and rubella (MMR), hepatitis B, human papillomavirus (HPV)) and the availability of simple field tests (G6PD and hypothyroidism screening) enabled the expansion of services. Staff training and financial support enabled this expansion.

Health information: Nutritional surveillance identified anaemic pregnant women and malnourished children and enabled the provision of food baskets for them as part of multi-sectoral poverty reduction; Teleprimary Care enabled better management of diabetes and hypertension by providing data for targeted monitoring and follow-up.

Governance: Community mobilisation and inter-sectoral co-ordination supported strategies for reducing disease risk factors. Grants were allocated for promotion, prevention, early screening and rehabilitation care. Illustrative examples are the mobilisation of teens through peer-to-peer counselling within school communities for targeted purposes such as tobacco smoking and drug use (PROSTAR) and for more general behaviour change purposes such as healthier lifestyles (Doktor Muda) (Ministry of Health Malaysia, 2005). New legislation established standards for care, including care of older people in private healthcare facilities, and also mandated the sale of iodised salts in districts with high risk of iodine deficiency disorders.

Sources: Government of Malaysia, 1998; 2012; 2018; Reference Lee and LeeMinistry of Health Malaysia, 2003; 2007; 2012; 2013.

4.3.2.2 Integration of Preventive and Curative Services in the Public Sector

Prior to the mid-1990s, curative PHC services were provided by:

• Outpatient departments (OPDs) of public sector hospitals and some satellite clinics for free or for a nominal charge.

• Public sector health centres and dispensaries, also free or for a nominal charge.

During the 1990s and early 2000s, two related organisational changes within the MoH led to better integration of preventive and curative services. First, the implementation of a policy decision to move OPDs out of hospitals and into health centres began in the late 1990s and continued incrementally over the next decade. Second, this move was followed by the re-organisation of services in the health centres to better serve the goal of developing people-centred PHC.

Transfer of OPDs.

Historically, hospital OPDs primarily catered for acute episodes of illness, rarely providing health prevention or promotion, and were not geared for the continuity of care essential for non-communicable disease (NCDs). Conversely, health centres had separate arms – the family health arm had good competence for providing preventive and health promotional services for family health aimed at clients in various phases of the life cycle (pregnancy, childhood, adolescence, old age), including individuals, families and communities on a long-term basis. However, the outpatient arm of the health centres mainly provided for walk-in patients. The utilisation of OPD services evolved, with the health centres gradually overtaking the hospital OPDs in terms of volume of utilisation (Figure 4.2).

Figure 4.2 Trends in the utilisation pattern of OPDs.

Source: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d.

Additionally, by the late 1990s, the proportion of patients with illnesses such as hypertension and diabetes, which require long-term management, was increasing. Meanwhile, public sector hospitals had difficulties managing outpatient services (OPDs), as their focus was mainly on secondary and tertiary care. Therefore, a policy decision was implemented to transfer OPDs from hospitals to health centres.

Re-organisation of health services.

The outpatient services in health centres were re-vamped to cater to the integration of preventive and health promotional services with illness management (Economic Planning Unit, 1996). The health centres adopted a new approach that integrated basic PHC concepts in addressing the continually expanding initiatives required to deal with NCDs. Box 4.5 summarises the concepts involved, and the illustrative case study on REAP-WISE (Reviewed Approach: Wellness, Illness, Support Services, Emergency Information) elaborates on the initiative. Imaging, laboratory and pharmacy facilities were upgraded progressively as staff and physical infrastructure became available (Economic Planning Unit, 1996; 2001). Communication between primary, secondary and tertiary care was strengthened, and information systems were upgraded to include electronic personal medical records that facilitated the integration of information from the various services that catered to each patient and family (Economic Planning Unit, 2001).

Box 4.5 The journey towards integration

The health centre services renewed the PHC concept with a new approach to accommodating its additional services, namely:

1. 1. Preventing and reducing disease burden by treating the ill, managing those with risks and preventing the onset of preventable risks.

2. 2. Enhancing healthcare delivery for fast access to safe and high-quality services with greater comfort in a hassle-free environment.

The wellness focus covers the life-course from antenatal to child and geriatric age for early identification of and management of medical conditions. All new activities for wellness are mapped against age group needs. Teams oversee policy development for the collective activities for each age group in order to integrate workflow processes, accounting for monitoring indicators, quantity and quality of human resources required, the diagnostic equipment, pharmaceutical requirements, and physical space for these activities. These workflow processes are then phased in at clinics nationwide.

(Reference Jaafar, Suhaili, Mohd Noh, Zainal Ehsan and LeeJaafar et al., 2007)

Gaps and limitations to the integration and re-organisation.

This re-organisation process required the re-allocation of budget and human resources between hospitals and health centres, and it also required re-engineering health information systems to provide real-time access to patient information for care providers at primary and secondary level. Table 4.5 illustrates the gaps and challenges in integration and re-organisation as well as the action taken to address such challenges.

Table 4.5 Gaps and challenges and action taken in integrating preventive and curative services

	Gaps and challenges	Action taken
Finance	Limited	Transfer of OPDs was done incrementally over a period of more than a decade
Health workforce	Rapid turnover of staff, particularly junior doctors who needed rotational postings as part of career development	Family medicine specialists (FMSs) were placed at health centres to oversee and manage patient care teams Multi-disciplinary team approach rather than individual doctors to serve clients from specified geographic zones
Medical products	Hospitals and health centres have separate budgets for pharmaceuticals – it was difficult to estimate the portion of hospital pharmacy budget needed for OPD as separate from inpatient care	State-level pharmacy departments took over budget management for pharmaceuticals for both health and hospital services
Service delivery	Existing building spaces and facilities could not accommodate the expanded functions Staff who had hitherto provided either curative or preventive/promotional services needed guidance on how to merge both components of care	New building designs for health centres were created for integrated services Laboratories and imaging services had to be updated to support the upgraded clinical services Practice guidelines were implemented for the newly expanded team of FMS, medical officer, medical assistant and nurses

Sources: Economic Planning Unit, 1996; Reference AwinAwin, 2003; Reference Awin2004.

4.3.2.3 Focus on Improving Quality of Care

During the late 1980s, the rising expectations of the public, as well as the strong commitment of professional leaders to quality of care, led to the introduction of a variety of quality improvement initiatives in the MoH (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). The scope of quality improvement was defined as including technical quality of care, client satisfaction and resource utilisation. This compares well with the statement 30 years later by the Organisation for Economic Co-operation and Development (OECD), the World Health Organization (WHO) and the World Bank defining the ‘measurable characteristics of quality as effectiveness, safety, people-centeredness, timeliness, equity, integration of care and efficiency’ (OECD et al., 2018). The key initiatives included raising the levels of competence in the PHC workforce and introducing systematic monitoring of quality followed by measures to identify and address systemic weaknesses that contributed to inadequate quality.

Higher levels of competence in the PHC workforce.

Medical officers, who were the front-line providers of care for illness episodes in health centres and OPDs, had no post-graduate or vocational training and had limited ability to manage more complex and chronic conditions, such as NCDs and mental illness. Years of effort by professional leaders (Reference RajakumarRajakumar, 1984) culminated in universities offering a new post-graduate training programme of Family Medicines, while the MoH created a new cadre of specialist: the family medicine specialist (FMS). This new category of FMS was expected to provide leadership in upgrading the quality of primary care services that included a more holistic approach of seamless care for health promotion, disease prevention, illness management and rehabilitation for individuals and families (Reference AwinAwin, 2004).

In tandem, the competencies of nurses and medical assistants were upgraded. The local production of allied health professionals, such as diagnostic radiographers, medical laboratory technologists, physiotherapists and dieticians, was stepped up with a higher level of qualifications and was modernised through integrated training approaches. Previously, the services of these allied health personnel were available only in hospitals, but now they were added to PHC teams (Ministry of Health Malaysia, 2006).

Quality monitoring and improvement strategies.

Hitherto focused on monitoring and improving ethnic and regional disparities in equitable access to care and health outcomes, PHC services added new dimensions to their performance monitoring (Box 4.6). Table 4.6 shows illustrative examples. The conglomerate of activities created a ‘bottom–up’ quality culture within the organisation.

Table 4.6 Quality monitoring and improvement: examples of experiences in primary care

Approaches to quality improvement	Examples	Benefits derived from the initiative
MoH Quality Assurance Programme adopted the approach of:Nationwide monitoring of selected indicators of system failure, for: Identification of outlier units in relation to agreed expected standards Analysis of root causes and implementation of remedial action	During the early stages of the programme, indicators were: Eclampsia of pregnancy Puerperal sepsis Severe neonatal jaundice During later stages, indicators included: Appropriate management of asthma Appropriate management of diabetes Appropriate admission to medical wards	Improved health information: – Accuracy and timeliness of data – Use of data in problem-solving Increased appreciation of quality and its relationship to clinical outcomes, resource utilisation and patient satisfaction
Participation in nationwide quality improvement strategies by health districts, health centres, hospital OPDs, laboratories and pharmacies	Quality control circles (waiting times, counter services) Client charter Work culture MS ISO 9000 certification	Improved managerial competence at local level Improved resource utilisation Improved client satisfaction

Sources: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d.; Ministry of Health Malaysia, 2004.

Box 4.6 Dimensions of quality that were monitored and improved

• Workforce skill levels and competence

• Outcomes of prevention and management of illness

• Client satisfaction

• Resource utilisation

4.3.3 PHC Services in the Private Sector

In the private sector, doctors (GPs) provide ambulatory non-specialist curative services on a fee-for-service basis. In the 1980s and 1990s, as rural to urban migration increased and the economy improved, the size and utilisation of the private sector increased rapidly (Figure 4.3).

Figure 4.3 Estimated outpatient visits to clinics per capita per annum, Malaysia, 1930s–2000s.

Note: Private outpatient refers to outpatient visits to both hospitals and clinics.Source: Health Policy Research Associates et al., 2013.

Box 4.7 summarises the characteristics of GPs, who provide about half of ambulatory care in Malaysia. Despite their importance in the health sector, governance and financing arrangements result in GPs having few incentives to provide prevention and promotion services. Their fee schedule is per visit and has not been adjusted for inflation over the past 15 years (Reference MaharajahMaharajah, 2018). It is not geared to reward the time and effort spent on health promotion. For many GPs, the fee is so low that it is not financially sustainable, and they rely on the sale of medications to maintain financial viability. Patients are free to move between doctors; doctor-hopping is frequent and therefore continuity of care could be compromised, and it can be difficult to build a trusting and long-standing relationship between providers and clients and their families. Additionally, there is no restriction on patients seeking primary care from doctors who practise as specialists in any discipline in the private sector. Therefore, specialist doctors are in direct competition with GPs.

Box 4.7 What are GPs?

• GPs are medical doctors.

• Few have any specialist or vocational training to function as providers of comprehensive PHC such as the requirements for GPs in the United Kingdom or Australia.

• Most GP clinics are urban and semi-urban, with fewer than six staff members. They use private laboratory and imaging services.

• GPs prescribe and dispense medicines.

• The public utilises GP services largely for acute illness episodes while largely visiting public PHC clinics for more chronic and complex conditions (Table 4.7).

Table 4.7 Top three reasons for encounters in public and private clinics

	Rate per 100 encounters
Public sector primary care clinics
Hypertension	31.3
Diabetes	22.5
Lipid disorder	18.5
Private sector clinics
Fever	28.3
Cough	26.5
Runny nose/rhinorrhea	19.4

Source: Clinical Research Centre, 2014.

A Quality and Costs of Primary Care (QUALICOPC) study showed that three-quarters of the patients who visited private clinics reported that they did not have a primary doctor to follow up on their condition (Reference Sivasampu, Mohamad Noh, Husin, Wong and IsmailSivasampu et al., 2016). Health information systems are underdeveloped. Few patients’ medical records are computerised and there are no incentives for recall and follow-up of patients who require long-term management. There is no systematic monitoring of the quality of care (Reference Sivasampu, Mohamad Noh, Husin, Wong and IsmailSivasampu et al., 2016). In contrast, for example, in Australia, there are targeted incentives for private sector primary care providers to support immunisation and cervical smear testing and for installing information technology (Reference KhooKhoo, 2002).

Additionally, GPs face serious economic challenges arising from the introduction of third-party administrators (see Case Study 4.2). On top of that, medical insurance schemes generally do not cover ambulatory care. In a recent survey, 70% of GPs interviewed cited as serious threats market competition from community pharmacies, and 55% cited market competition from the public sector 1Malaysia clinics (Reference KennyKenny, 2017).

Box 4.8 System observations: when systems outcomes diverge from stated goals

The policy environment in which private clinics currently operate presents obstacles to preventative and chronic care. This shows how stated goals, such as the aim of the MoH to increase integration and comprehensiveness of primary care, may differ from systems outcomes. Policies and resources for public clinics have enabled significant advances toward these goals. However, private clinics operate under fee structures, lack of integrated information systems and other policy obstacles that create barriers to preventative and chronic care. Private GPs have persisted in health promotion despite these obstacles (Table 4.9). The MoH needs to invest in an enabling system for private GPs to sustain and maximise their contribution to comprehensive primary care.

4.4 Summary of the Malaysian Experience

Although the PHC services predated the Alma Ata Declaration of 1978, the guiding principles used in Malaysia were akin to those formulated in Alma Ata. Over 60 years, these services evolved in incremental stages in response to population dynamics and behaviour, changing disease patterns and economic pressures, taking advantage of local opportunities and recognising constraints. The government assumed responsibility for free public sector services that led the way and dominated the subsequent evolution of PHC in the country. Achieving equitable access for a wide range of ‘essential services’, including PHC services, has remained a cornerstone of the evolution. These services included preventive and health promotional services, including nutrition, as well as curative services provided at hospital OPDs and by the private sector.

PHC services retained the focus on people throughout the evolution – variously reaching out to communities to mobilise them in improving or sustaining health. The process of evolution saw a progressive expansion of the range of preventive and promotional services – beginning with pregnancy, childbirth and infancy and progressing through each age group to old age while simultaneously addressing specific localised concerns, such as iodine deficiency and mental health, as they arose. The parallel evolution of ambulatory curative services saw a progression from managing acute illness episodes to dealing with illnesses that require long-term care, such as hypertension and diabetes. The evolutionary process recognised the benefits of merging the parallel development of preventive/promotional services with the curative stream, and the system was able to accomplish rather complex organisational re-structuring to achieve such merging.

The other cornerstone of the evolution was the continuing thrust to improve quality. The features of the success in Malaysia are: strong and sustained leadership and commitment to quality; adherence to basic principles of quality improvement, including monitoring; and improvement that originated from the service providers themselves, thereby reducing the fear of punitive repercussions and increasing accountability and transparency.

Several challenges surfaced from time to time. As elaborated on in Chapter 8, some were addressed successfully, while others continue to haunt the evolutionary process. For example, the evolving profile of a workforce with higher qualifications has created demands for higher remuneration and better career paths. The workforce in the public sector PHC service is part of the larger civil service in the country. Hence, change is fraught with repercussions. Meanwhile, the private sector is reluctant to absorb higher-paid categories and prefers task-shifting, for example, using nurse assistants in place of trained nurses.

In the past, the private sector has complemented the public sector by providing care for those who were able to pay out of pocket for prompt and convenient care. The last couple of decades has seen publicly funded primary care growing faster than the private sector. While the public sector moves closer to comprehensive primary care and keeps an eye on quality and responsiveness, the private sector is struggling with issues of governance, financing, skills in the workforce and disincentives to move towards comprehensive care. There is a risk that public perceptions of public and private services will change. Wealthier sections of the population might change their health-seeking behaviour accordingly and drift towards the highly subsidised public sector despite being able to afford private services. This would have a negative impact on PHC by overburdening the government budget. Efforts to establish a more collaborative model of operation have been repeatedly frustrated by political pressures and priorities.

4.5 Key Messages from Malaysia’s Experience

5.1 Introduction

Secondary and tertiary care (STC) as discussed in this chapter are services provided in a facility such as a hospital or an ambulatory care setting by a specialist that require more specialised knowledge, skill or equipment than can be provided at the primary care level. The Alma Ata Conference on Primary Health Care (PHC) clearly defined the role of STC within PHC:

Mahler, the Director-General of the World Health Organization (WHO) from 1973 to 1988, furthered the concept, for example, by stating in 1980 that ‘people in need must have access to skilled surgical care at first-line referral hospitals’ (Reference MahlerMahler, 1980). The evolution of STC in the Malaysian health system demonstrates the challenges and achievements in implementing these concepts.

This chapter discusses how access to and quality of STC improved progressively in Malaysia during the 60 years since independence and how the system is currently grappling with the challenge of providing affordable, integrated, seamless care. It discusses the dynamic interactions of various components of the health system and their influence on STC and the influence of the larger Malaysian ecosystem, such as political, socio-economic, demographic and population behaviour.

The appendices provide details of the analysis that underpins the chapter. Appendix I illustrates the application of systems thinking, while Appendix II provides illustrative details of the interactions between components of the health system that are defined in the WHO health system ‘building blocks’ (see Chapter 1) and also the interaction between the health system and the larger ecosystem.

5.2 The Early Phase (1960s and 1970s): Increasing Access and Reducing Disparity

At independence, Malaysia inherited secondary care services consisting of 10 major hospitals and 56 district hospitals concentrated mainly in urban centres in the West Coast states of Peninsular Malaysia (Box 5.1). Many of them were dilapidated (International Bank for Reconstruction and Development, 1955). Doctors and nurses were in short supply, and specialists were almost entirely expatriate.

5.2.2 Hospital Services Supported PHC

Even before Mahler’s historic 1980 address, the Malaysian district hospitals were first-line referral facilities. They provided support for PHC through secondary care for patients referred from the national disease control programmes, such as those for malaria, tuberculosis (TB) and leprosy (see Chapter 6), and the rural health services, particularly for pregnancy, childbirth and illnesses of childhood (see Chapter 4). The staff of these hospitals were mainly nurses, midwives, medical assistants and junior doctors who were able to address emergencies, minor surgery, childbirth and its simpler complications, and the management of illnesses that required hospitalisation. However, the hospitals had neither the staff and the operating theatres for surgery nor the laboratory and imaging facilities for more complex secondary care. However, the district hospitals did have ambulances that provided free transport links on the one hand between district hospitals and state-level hospitals that had more sophisticated facilities and on the other hand between hospitals and health centres that provided PHC. These ambulances ferried patients, staff and laboratory samples and were crucial in providing the referral link between primary and secondary levels of care.

State-level hospitals provided, at a minimum, specialist care in internal medicine, surgery, obstetrics and gynaecology, paediatrics, and anaesthesia, with appropriate support services (Reference IsmailIsmail, 1975). During this period, several existing, dilapidated state-level hospitals were re-built or refurbished. The government highly subsidised medical care in the public sector hospitals and therefore imposed only a nominal charge on patients at the point of care (see Chapter 9).

The development of STC required the production of a sufficient workforce of doctors and nurses. However, the number of doctors produced was small, as there was only one local medical school (later three) (see Chapter 8). Furthermore, there was no local facility for postgraduate specialist training for Malaysian doctors, and very small numbers were sent abroad annually for training, mainly to the United Kingdom. On their return, they slowly replaced the expatriate specialists and provided specialist services and leadership for the different clinical disciplines. However, the rapid production of nurses and assistant nurses (see Chapter 8) facilitated district hospitals in providing selected forms of secondary care services, and this, to some extent, compensated for the much slower production of doctors. Working alone or with doctors, medical assistants provided secondary care for communicable diseases and other common ailments that did not require specialist care. Nurses who had an additional year of midwifery training became nurse-midwives and, assisted by trained midwives, managed uncomplicated childbirth in all hospitals. The number of district hospitals increased, as did hospital beds for TB, leprosy and childbirth. The hospitals also provided support for the rapidly developing primary health care services (Box 5.2).

Box 5.2 Secondary care–supported PHC

The hospitals provided support for the evolution of PHC. The key features were:

• Ambulances that provided free transport for patients, staff and laboratory samples between front-line PHC facilities, first-line hospitals and higher-level hospitals.

• Doctors (particularly obstetricians and paediatricians) who worked in state-level hospitals participated in training nurses and medical assistants who subsequently served in district hospitals or PHC facilities.

• This helped establish rapport and trust between staff at PHC and STC level, thereby fostering timely recognition and referrals from peripheral facilities. Such referrals were given priority in the larger hospitals, thereby enhancing the credibility of the staff in the peripheral facilities.

During the subsequent three decades, advances in medical products and the success of the disease control programmes enabled hospitals to reduce the beds provided for acute communicable diseases (Figure 5.1). Also, improved access to STC for pregnant women contributed to the reduction in maternal deaths and sustained the demand for institutional childbirth. Box 5.3 provides illustrative examples.

Figure 5.1 Evolving profile of types of hospitals, number of TB and leprosy beds, and childbirth in hospitals.

Source: Calculations by author based on data from Reference Suleiman and JegathesanSuleiman and Jegathesan (n.d.).

Box 5.3 Illustrative examples: STC-supported public health

Hospital care had a major role in reducing incidence of TB (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.).

• In 1960, beds reserved for TB patients accounted for 25% of hospital beds.

• The aim of hospital management was to treat patients to render them non-infective before sending them back into the community.

• The advent of effective drugs shortened inpatient stay and enabled a reduction in TB beds by 1996.

Maternal deaths declined through an effective and credible system that provided safe childbirth care with timely access to STC (Reference Pathmanathan, Liljestrand, Martins, Rajapaksa, Lissner and de SilvaPathmanathan et al., 2003).

• Essential obstetric care: By 1976, overwhelming demand for childbirth in hospitals resulted in maternity units having extremely high bed occupancy and turnover rates (Institute for Public Health, 1983).

• Emergency and comprehensive obstetric care: Ambulances from rural health centres and district hospitals provided prompt transport for the referral of patients with obstetric complications to hospitals with higher levels of care that included specialist care from obstetricians.¹

The rapid increase in the utilisation of hospitals throughout the country demonstrated the rising demand for STC (Figure 5.2).

Figure 5.2 Utilisation of Ministry of Health hospitals in Peninsular Malaysia, 1970 and 1996.

Source: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d.

Although the availability of hospital services increased, they barely coped with the rate of population increase. Fifteen years after independence, the disparity in the availability of STC between the more urbanised West Coast states in the Peninsula and the less developed East Coast states² remained evident (Table 5.1).

Table 5.1 Regional disparity in secondary care in different regions of Malaysia, 1972

	Acute beds (per 1,000 population)	Admissions (per 1,000 population)
West Coast states	2.16	37.25
East Coast states	1.69	22.50
Peninsular Malaysia	2.08	34.58
East Malaysia	1.94	n.a.
Malaysia	2.05	n.a.

Source: Calculations by author based on data from Reference Abdul, Gurmukh and MatinezAbdul et al. (1974).

n.a. – not available

5.3 The Second Phase (1980s and 1990s): Drive for Better-Quality Access

5.3.2 More Sophisticated Clinical Care

Doctors with postgraduate training in specific disciplines had the higher level of competency required to provide comprehensive STC. Specialist training in local universities for doctors began during the 1980s (see Chapter 8) and resulted in the availability of larger numbers of doctors with specialist qualifications and the establishment of a wider range of specialised units in public sector hospitals. This, in turn, triggered the upgrade of laboratory and imaging services and the training of allied health personnel, such as medical laboratory technologists and radiographers, for these services (see Chapter 8). To promote equitable access to specialised medical services, the Ministry of Health (MoH) adopted a regional development approach. State-level and larger district hospitals were categorised into three levels, with Level 1 consisting of five basic medical specialities, Level 2 having six additional specialities and Level 3 consisting of further specialisation within narrow fields of the more general disciplines (such as cardiologists and neurologists within the broader field of internal medicine). Every region in the country had one hospital of Level 3 status and at least one with Level 2 status. The availability of speciality services increased from 12 units per million people in 1970 to 16 units in 1997 (Table 5.2).

Table 5.2 Increased availability of specialist care in MoH hospitals, 1970–1997

	1970	1980	1997
Peninsular Malaysia	121	220	283
Sabah	4	15	31
Sarawak	5	25	38
All	130	260	352
Units1 per million people	12.1	18.9	16.2

Source: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d.

¹ One unit was equivalent to one or more specialists in a specialist unit or department.

With the growing numbers and types of specialist qualifications from various universities and countries, professional bodies and the MoH were concerned about safeguarding the standards of competence to preserve the quality of care. This triggered governance actions in the form of the establishment of procedures for credentialing and certifying specialists (see Chapter 8).

The increasing numbers and types of sophisticated clinical services required better laboratory and imaging services. For example, Table 5.3 illustrates that the upgrading of laboratory services in MoH hospitals was linked to the type of specialist services available. The upgraded laboratory services required the appropriate allied health personnel with higher levels of qualifications. Appropriate training programmes and deployment strategies came into place.

Table 5.3 Laboratory services increased in sophistication in tandem with the availability of specialist clinicians

Type of facility	Laboratory service
No specialist doctor	Medical laboratory technologist (MLT)
Specialist doctor but no pathologist	Biochemist OR microbiologist plus MLT
Pathologist	Biochemist AND microbiologist plus MLT
National referral level (IMR)	All plus sub-speciality pathology services
IMR and universities2	Very sophisticated tests and research

Sources: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d.;

Reference Suleiman and Jegathesan² Institute of Medical Research (IMR).

The developments required higher investment and maintenance costs. The rising gross domestic product (GDP) facilitated the financing of these investments.

Figure 5.3 provides a summary of the dynamic interactions in the health system as it moved towards providing more sophisticated clinical services.

Figure 5.3 Dynamics of providing more sophisticated clinical services.

5.3.3 Private Sector

Meanwhile, there was high demand for STC in the private sector, leading to the rapid expansion of hospitals (Table 5.4). In 1997, 70% of private hospitals were small, with less than 20 beds, and several were in buildings not suited for providing quality care (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). Concerned about quality standards, the government enacted legislation (Government of Malaysia, 1998) with stringent standards for physical structure and with corporate and clinical governance, including procedures for monitoring quality (see Chapter 12). Enforcement began in 2006.

Table 5.4 Rapid growth of private hospitals, 1980–1996

Year	No. of private hospitals	No. of private hospital beds	Private as % of all hospitals	Private as % of all admissions
1980	50	1,171	4.3	n.a.
1985	133	3,559	11.5	12
1990	197	4,675	14.1	14
1996	215	7,417	20.4	17.2

Source: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d. (data extracted from Ministry of Health Malaysia annual reports 1981, 1985, 1990 and 1996).

n.a. – not available

In parallel, there was high demand for care by the few specialist doctors who had established larger private hospitals since the mid-1970s. Recognising a good business opportunity, corporate entities moved in and bought up the larger hospitals. Corporate ownership led to a change in philosophy. While catering for the demands of the well-to-do who could afford private sector fees, these hospitals now also paid serious attention to profit margins. Their expansion and development plans reflected this change (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). One evident feature was the trend towards the rapid proliferation of higher-cost technology in the private sector as compared to the public sector (Table 5.5). These hospitals were concentrated in the wealthier regions of the country, thereby challenging the objective of equitable development.

Table 5.5 Distribution of high-cost imaging technology in MoH and private hospitals, 1997

	MoH hospitals			Private hospitals
	CT scan1	Mammogram2	MRI3	CT scan1	Mammogram2	MRI3
Nine West Coast states	11	10	2	42	32	11
Three East Coast states	3	3	0	2	1	0
Sabah and Sarawak	3	2	0	4	3	2

Source: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d.

¹ Computed tomography (CT): The MoH had one unit per state except for the capital city, Kuala Lumpur, which had four units. Private hospitals had 17 units in Kuala Lumpur and neighbouring Selangor and 10 units in Penang.

² Mammogram: The MoH had one unit per state except Kuala Lumpur, which had three units. Private hospitals had nine units in Kuala Lumpur, four units in Selangor and eight units in Penang.

³ MRI – magnetic resonance imaging.

The MoH initiated health technology assessment (HTA) as a means of rationalising the acquisition of newer technology. The output of the HTA unit provided input into the formulation of policies in the public sector and provided the basis for the development of clinical practice guidelines (CPGs), purchasing decisions, drug regulation and health-related advertisements (Reference Roza, Junainah, Izzuna, Ku Nurhasni, Mohd Yusof and NoormahRoza et al., 2019). However, there is limited information on whether the private sector uses the HTA information for guiding the development of technology.

Box 5.4 System observations: shifting the healthcare burden to the private sector

The development of the private health sector in Malaysia is an example of how solutions to health system challenges can create long-term, irreversible changes to the system. Rising demand for more sophisticated medical care in the 1960s and 1970s led to a gap in public hospital capacity as limits in financial and human resources caused capacity to lag behind demand. This demand continued to increase in the 1980s and 1990s, so the rise and rapid expansion of private sector hospitals was welcomed by the public sector. While the private sector alleviates the burden of the public sector in some ways, it has become apparent that it draws medical practitioners, especially specialists, away from the public sector (Figure 5.4). The public sector thus has had to invest further resources and change policies to retain medical practitioners to keep up with healthcare demands.

Figure 5.4 Rising demand for medical care outpaced public hospital resources, creating a gap in public sector capacity (B1). The expansion of private sector hospitals (B2 loop) offered a means of bridging this gap with private sector resources. However, private healthcare has drawn on medical personnel from the public sector, becoming another source of pressure on public sector capacity (R1 loop). This is a well-known system archetype known as ‘shifting the burden’, in which actions taken to address the outcomes of a problem (a gap in hospital capacity) can exacerbate the underlying causes of that problem (public hospital human resources).

Private sector care has become corporatised and supporting structures such as private insurance and medical tourism have been developed, creating a self-sustaining industry. In addition to health workforce challenges, the resulting fragmentation of healthcare providers and financers has created challenging tensions regarding the locus of responsibility for the provision and payment of healthcare.

5.3.4 Quality: Monitoring and Improving Outcomes

In the late 1980s, the government of Malaysia initiated nationwide efforts to improve quality in the public sector. The MoH was one of the agencies that led the way in implementing the national call to action. The National Quality Assurance Programme (QAP) of the MoH spearheaded efforts to instil concern for quality as a culture at all levels of the organisation. It established a system for the explicit measurement of outcomes. This included monitoring performance trends in clinical care, patient satisfaction and better use of resources (physical, time and human resources). Box 5.5 provides illustrative examples.

Box 5.5 Key features of the QAP for secondary and tertiary healthcare services in the public sector

Approach and Methods

• Peer groups in each clinical discipline or hospital management group selected performance indicators.

• The MoH collected data on the indicators, analysed and rank-ordered the performance of individual hospitals, and shared the results with all stakeholders.

• Outliers were encouraged to analyse the factors contributing to their status and were helped to remedy issues.

• Performance trending enabled peer groups to discard or replace indicators periodically to move towards more sensitive and specific monitoring of performance outcomes.

Examples of Results

• Improvement in the management of acute myocardial infarction.

• Decreases in waiting time to see doctors and decreases in rejection rates for X-rays and laboratory specimens.

• Improved client satisfaction with counter services (e.g. pharmacy counters), cleanliness and facilities. For example, a small district hospital (Kuala Krai) in one of the more disadvantaged states won a national award for improving the quality of public services in 1995.

Source: Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d.

The thrust for improving clinical outcomes (Figure 5.5) provided a fillip for strengthening clinical governance measures such as the development and use of Clinical Practice Guidelines (CGPs) and for stronger implementation of existing initiatives such as clinical audits and mortality reviews. It also contributed to improving the quality of data for health information (see Chapter 10), particularly in terms of accuracy of International Classification of Diseases (ICD) coding and timeliness of data, as healthcare providers became aware that this had a critical impact on the accuracy of indicators that measured performance.

Figure 5.5 Dynamics of improving clinical outcomes and establishing a quality culture at every level.

The drive for improved outcomes of clinical care led to the establishment of disease registries for selected conditions such as end-stage renal disease (ESRD) and cancer, which are managed largely at the secondary care level. The registries are meant to provide information on disease conditions as well as treatment effectiveness and cost. The National Renal Registry, established in 1993, was a trailblazer, and it monitors trends in the quality, cost and effectiveness of different modalities of care for ESRD (Reference Lim and LimLim & Lim, 2004). It provided the data for a cost analysis that enabled the move to public–private partnership in the provision of dialysis (Reference Lim, Lim, Wong, Ahmad, Singam and MoradLim et al., 1999).

The thrust for better outcomes in patient satisfaction and use of resources (Figure 5.6) stimulated a need for increased managerial competence at all levels of the MoH system (see Chapter 8). It also facilitated the growth of team approaches and the use of health systems research as a management and problem-solving tool. Hospitals won national ‘quality awards’ for improving client satisfaction and reducing waiting times (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). Budgeting systems were modified to provide greater authority to hospital managers to manage funds more flexibly to respond to local requirements (see Chapter 9). However, as the MoH was part of a larger public sector system, there were constraints. The degree of flexibility that could be decentralised was limited due to financial rules and regulations (see Chapter 9). Similarly, as all MoH staff are part of the federal civil service (see Chapter 8), constraints arose. For example, nurses with training and credentials in one discipline had to move to another discipline to further their careers (Institute of Health Management, 2006).

Figure 5.6 Dynamics of improving resource utilisation and client satisfaction.

The thrust for improved resource management extended to strategies for improving the maintenance of building structures and biomedical equipment in public sector hospitals. New posts were created for hospital-based engineers, and maintenance services were outsourced to private contractors, with hospitals retaining oversight of the contractors’ performance (see Chapter 7). Performance indicators of quality applied not only to clinical aspects of care but also to support services.

The quality-improvement measures also strengthened support from STC for PHC services (Box 5.6).

Box 5.6 Further initiatives strengthened STC support for PHC

Various measures contributed to further strengthening supportive linkages between hospitals and PHC. Examples include:

• In the QAP, the senior specialist for a discipline in each state hospital took responsibility for improving quality in all facilities. For example, the state obstetrician provided oversight to prevent maternal deaths throughout the state and therefore liaised with district hospitals, health centres and rural midwives, resulting in an improvement in the early detection and referral of complications of pregnancy (Reference Pathmanathan, Liljestrand, Martins, Rajapaksa, Lissner and de SilvaPathmanathan et al., 2003).

• Outbreaks of dengue fever resulted in health inspectors visiting hospitals for epidemiological investigations that strengthened communication between STC and PHC. Conversely, health centres and private clinics used clinical management protocols originating from hospital-based specialists to improve the quality of care for dengue patients.

Supplementary Table 5-b in Appendix II summarises the interactions in the health system during the 1980s and 1990s (STC development Phase 2).

5.4 The Third Phase (2000–Present): Drive towards Integrated, Seamless, High-Quality Care

By the beginning of the new century, the health sector still fell short of the requirements for equitable access to quality care and faced several threats that arose from the ‘successes’ of the past. Section 5.4.1 and Case Study 5.1 analyse the interactions between various components of the health system in addressing some of these threats.

The major threats to STC included:

• In the public sector: Rapid increase in specialisation that led to increasing fragmentation at both clinical and managerial levels.

• In the private sector: Increasing conflict between medical care as a profit-oriented business and as a service to improve the welfare of the community.

• Conflicts arising from the changing roles in the public–private split of the health sector.

The health sector reactions to these threats included (but were not restricted to):

• Implementing organisational change to address the fragmentation that arose from increasing trends of specialisation.

• Taking advantage of changes in medical technology and information communication technology (ICT) to improve access and efficiency while reining in escalating costs.

• Attempting to use governance measures (legislation, financing) to address the challenges and governance gaps in dealing with the public–private split in the health sector.

5.4.1 Organisational Change

In the public sector, there was a rapid increase in the types of clinical specialist units in hospitals and the types of programme management units at national and state levels. Communication between organisational units deteriorated. For example, communication between hospitals and health centres, between hospital outpatient departments (OPDs) and wards, between departments of different clinical disciplines and between district- and state-level hospitals became more challenging (Reference SuleimanSuleiman, 1999). This carried threats to continuity of care for patients, such as people with diabetes, who required long-term care provided by more than one unit or department. There was an increased risk of worse-than-desired health outcomes.

Furthermore, duplications and missed opportunities could contribute to organisational inefficiencies, resulting in rising healthcare costs. The MoH addressed these threats by adopting a policy to ‘provide seamless health care by enhancing integration’ (Institute for Public Health, 1999). Two structural changes of note occurred. First, OPDs in hospitals were moved to health centres that were better suited to provide seamless preventive, promotive and curative care in ambulatory settings and adopted family and community perspectives in the management of conditions such as NCDs. Chapter 4 discusses this initiative.

The second strategy was the formation of hospital clusters to increase access to specialist care and improve utilisation rates in the smaller hospitals. The smaller hospitals had quite a large proportion of unused beds. During the previous experience in the regionalisation approach to improving access, specialists visited non-specialist hospitals. This proved unsuccessful because the smaller hospitals did not have the facilities or expertise to support specialist care. In the cluster concept, a major hospital that had a wider range of specialities formed a cluster with a few neighbouring smaller hospitals to share financial and human resources and equipment. In addition, there was an initial investment in upgrading surgical facilities in the smaller hospitals. Specialists and their teams from the lead hospital provided specialist services at the smaller hospitals on a visiting basis, negating the need to move patients to the major hospital. There was investment in training to enable staff at the smaller hospitals to provide adequate follow-up care after the team from the major hospital had provided treatment. The pooled budget enabled the sharing of financial and material resources such as drugs, equipment and travel between hospitals. There was shared responsibility for the outcomes of care. Initial assessment indicated that these measures provided relief from overcrowding in the major hospital and increased patient satisfaction and cost–benefit in the management of patients with moderate or serious illness. However, they did not increase utilisation rates in the smaller hospitals. Barriers to sustaining or expanding this initiative included frequent transfer of human resources from the smaller hospitals, thus negating the investment in upgrading capacity, and inadequate recognition of the need for the initial additional investment to prepare smaller hospitals to support specialist services (Institute of Health Management, 2016; 2017). Despite these initiatives, the bed occupancy rates of the non-specialist hospitals remained below 50% (Figure 5.7).

Figure 5.7 Bed occupancy rates in MoH hospitals.

Source: Ministry of Health Malaysia, 2016.

Another aspect was the strengthening of referral systems. Within the MoH system, there were continuing efforts to improve the logistics and communication of referral between primary, secondary and tertiary care levels. This included strengthened governance through the refinement and clarification of procedures, expected standards and technological support, for example, through the telehealth project that enables real-time sharing of patient data between primary and secondary care levels, thereby contributing to quality of continuity of care for patients (Reference AllaudinAllaudin, 2014). However, other major challenges arose from governance features of the health system. For example, patients have direct access to specialist clinics in both the public and private sectors without going through primary care (Reference Yiengprugsawan, Healy, Kendig, Neelamegam, Karunapema and KasemsupYiengprugsawan et al., 2017). This encourages the bypassing of primary care. In addition, in the private sector, it encourages rivalry between primary and specialist care providers, which in turn raises the risk of failure to refer conditions that require higher levels of competency. Additionally, evidence suggests that feedback and referral from STC services to primary care in the public sector is weak (Table 5.6). In larger hospitals in both the public and private sectors, rules for referral between different clinical disciplines have not been established.

Table 5.6 Referral experiences reported by doctors in public sector health centres

	% of doctors stating
	Usually or always	Occasionally	Seldom or never
Received patient records from previous doctor	36.2	51.6	12.2
Used referral letters	99
Received feedback from specialists	19	30.8	50.2
Obtained discharge report from hospital	27 (within 4–14 days)	13.7 (delayed > 14 days)	58.4

Source: Reference Sivasampu, Mohamad Noh and ChinSivasampu et al., 2015.

5.4.2 Advances in Technology

Technological advances affected STC profoundly. Two illustrative examples of the influence of technology on the delivery of STC services are telemedicine and day-care surgery.

Telemedicine.

The MoH introduced telemedicine progressively in several districts to increase access and reduce costs by enabling specialists based at larger centres to provide, through teleconsultation, diagnostic and therapeutic advice to doctors in hospitals without specialists or with a smaller range of specialities. Reference Yusof, Neoh, Hashim and IbrahimYusof and colleagues (2002) noted that the introduction of telemedicine increased access to STC in the remote, less accessible districts, such as Beluran and Kudat in Sabah, and led to ‘enhanced diagnostic options, cost savings and better health outcomes’. By 2016, telemedicine had increased to 45 facilities and 60 stations throughout the country (Ministry of Health Malaysia, 2016). Nurazean and colleagues reviewed the system and noted that the careful selection of sites influenced the usefulness and utilisation of teleconsultation. Factors in selection included sufficient need (i.e. inadequate expertise to address more complex problems), difficulty of physical access between sending and receiving sites, and discipline-specific guidelines (certain types of cases in each discipline are not amenable to distance guidance) (Reference Nurazean, Win, Singh and MasromNurazean et al., n.d.).

Day-care surgery.

Medical technology such as advanced anaesthesia and minimally invasive surgical technologies contributed to increasing numbers of day surgeries, for example, cataract surgery, laparoscopy and other endoscopies that require short postoperative monitoring and recovery. The evaluation of day-care cataract surgery has been possible through the National Eye Database, which facilitates the tracking of trends in cataract surgery. It provided evidence that contributed to improvements in techniques and technology, as reflected in practice patterns and outcomes (Table 5.7). An increasing proportion of cataract surgery is being performed as day-care, and visual outcomes have improved, indicating improved quality. The success of the day-care centres for cataract surgery is attributed also to the availability of dedicated, well-trained teams of care providers, including highly trained technicians, nurses, specialists and sub-specialists.

Table 5.7 Cataract surgery profiles, 2002 and 2015

	2002	2015
Cataract surgeries	12,798	44,534
Day-care (%)	39.3	69
Phacoemulsion (%)	39.7	87.9
Local anaesthesia (%)		93
Intraoperative complications (%)		5
Unaided visual outcome 6/12 or better (%)		55.1
Visual outcome 6/12 or better with spectacles (%)	87	95.1

Source: Reference Goh, Aziz Salowi, Adnan and Sa’atGoh et al., 2016.

Day-care surgery provides an avenue for controlling costs (Evaluation of Specialist Complex and Ambulatory Care Centre, 2018). The day-care centre approach has also contributed to integrated care, with specialists from various disciplines managing patients simultaneously. For example, endocrinologists managing problematic diabetic patients have simultaneous input from orthopaedic and vascular surgeons.

Figure 5.8 Harnessing technology to improve access to seamless, integrated care.

5.4.3 Governance Challenges Affecting STC

The fragmentation of clinical services is a challenge and occurs in at least at two dimensions of care. First, several clinical disciplines are compartmentalised into sub-specialties. Sometimes, the care provider in sub-speciality case management focuses on managing a particular condition to the exclusion of co-morbid conditions. At STC level, technological advancement necessitates multidisciplinary knowledge and skills and cross-discipline references in managing patients with multiple complex conditions. Care providers require the appropriate skills and attributes to recognise when cross-referral is needed and facilitate seamless cross-referrals. Currently, in Malaysia, the policies regarding intra- and inter-facility referral in both public and private sector clinical networks are weak.

Furthermore, clinicians at the PHC level who refer patients to STC levels of care have difficulties identifying the person or department in the hospital responsible for co-ordinating and facilitating such referrals. This situation is further complicated because patients have the right to an informed choice of providers that best fit their medical needs and financial resources. Many patients prefer to skip primary care facilities in favour of direct appointments at specialist clinics or hospitals, particularly in the private sector.

Another dimension of the fragmentation of STC is evident in the fragmentation between the public and private sectors, each with different payment and governance mechanisms. During the first 40 years after independence, the fragmentation of the Malaysian healthcare sector into the public and private sectors appears to have assisted the national goal of improving equitable use of healthcare (see Chapters 3 and 9). Although the schism created tensions, particularly in the distribution of the workforce, it also enabled the wealthier segment of the population who could afford it to utilise private hospitals, thereby facilitating the public sector to provide for the lower-income groups (Figure 5.9) (Health Policy Research Associates et al., 2013).

Figure 5.9 Composition of inpatient care utilisation in public and private sector by socio-economic status.

Source: Health Policy Research Associates et al., 2013.

However, during the most recent two decades, fresh challenges have surfaced, arising largely from underlying governance structures and financing mechanisms.

5.5 Conclusion

In summary, STC evolved in response to demand from the larger ecosystem. Economic growth, population behaviour and epidemiological patterns created political pressures that in turn resulted in an ever-increasing demand for STC.

The evolution of STC has moved from selective secondary care towards increasingly comprehensive STC, moulded by the ability of the health workforce to respond to demands for higher levels of competency and by the availability and capabilities of medical products and technology.

The enabling sub-systems, in turn, have influenced the evolution of the healthcare provider sub-system. These sub-systems comprise finance (sources, recipients and modalities), health information (availability, quality and use) and governance (managerial competence, governance structures and legislative tools) that either enable or constrain the evolution of the provider sub-system.

The outcomes of the healthcare system, in turn, have influenced the larger ecosystem, thereby creating a perpetual cycle (Figure 5.10).

Figure 5.10 Interactions between the larger ecosystem and the healthcare provider sub-system with its enabling or constraining sub-systems.

5.6 Key Messages from Malaysia’s Experience

6.1 Introduction

Disease prevention and control programmes aim to reduce disease incidence, prevalence, and morbidity or mortality (Reference DowdleDowdle, 1998). Within the first thirty years since independence in 1957, Malaysia successfully eradicated or drastically reduced the occurrence of several serious communicable diseases (CDs) (Figure 6.1). During the next thirty years, Malaysia had some success as well as limited or no progress in dealing with non-communicable diseases (NCDs), re-emerging CDs (such as dengue) and other new and emerging CDs (such as influenza H1N1). This chapter analyses the development and evolution of disease control in Malaysia over the sixty years since independence (1957–2017). It explores and analyses the influences and interactions of various components of the health system and beyond the healthcare system in controlling diseases. The chapter does not attempt to address all the threads of disease control efforts in Malaysia. Instead, specific examples of disease control programmes illustrate key features that contributed to the success or limited progress of control efforts.

Figure 6.1 Incidence rate of communicable diseases per 100,000 population, Malaysia, 1975–1997.

Sources: Ministry of Health, 1983; Reference Suleiman and JegathesanSuleiman and Jegathesan, n.d.

Disease control programmes in low- and middle-income countries commonly use vertical or campaign-style programmes. Horizontal programmes, on the other hand, rely on a system of health services. Reference Atun, Bennett and DuranAtun, Bennett and Duran (2008) discuss the advantages of vertical programmes (rapid response; quick, economical and efficient solutions; better accountability within limited resources and timeframe) and constraints (donor- and value-driven (responsive to disease, lacking in people-centred care); expensive to sustain; creating subsequent redundancies, inefficiency and fragmentation in the health system). They note that some vertical programmes are standalone, completely separate and parallel to mainstream health services, and continue to remain in that mode. Others are designed as time-limited programmes that are then integrated with extant health services; yet others have varying degrees of integration from inception.

This chapter describes Malaysia’s developmental experience in disease control and explores how the characteristics of prevalent diseases and the health system have combined to influence the design of disease control programmes and their subsequent integration into the mainstream health service.

6.2 The First Phase (1957 until the Mid-1980s): Control of Communicable Diseases

By the time it gained independence, Malaysia had already controlled several major epidemic contagious diseases (smallpox, cholera, plague). The main CDs of concern were vaccine-preventable diseases (neonatal tetanus, diphtheria, pertussis (whooping cough)), which took a heavy toll of infant lives; vector-borne and water borne diseases (malaria, dysentery, typhoid and paratyphoid, and endemic cholera), which affected the productivity and lives of the work-aged population groups; and tuberculosis (TB), which caused illness and premature death in both adults and children (Box 6.1).

As elaborated in Chapters 3, 4 and 5, during the 1960s until the mid-1980s, healthcare for the predominantly rural population increased gradually, with expanding rural health centres and district hospitals and gradually increasing availability of nurses, midwives, hospital assistants (later known as assistant medical officers) and sanitation staff. Training and competence in public health and programme management was limited and concentrated mainly at the national and state levels. Monitoring systems were rudimentary. The high incidence and prevalence of the common CDs was a heavy burden for the nascent health services. The rationale for adopting vertical approaches for controlling selected CDs was to provide additional resources targeted at rapidly reducing specific disease burdens to enable the young health service to assume responsibility without being overcome by these diseases to the detriment of other functions.

A distinctive feature of Malaysian development was that disease control programme funding was from domestic sources and channelled through the budget allocated to the Ministry of Health (MoH). Malaysia generally does not receive significant bilateral aid for health (World Health Organization, 2017). Foreign aid was mainly in terms of consultant expertise for designing programmes and training staff, management and treatment protocols, and designing monitoring and surveillance systems. Therefore, the new programmes aligned as closely as possible to national health development strategies. There was no need to provide accountability to external donors. On the other hand, there were strong incentives to avoid unnecessary domestic financial burdens by using existing facilities and staff and avoiding human resource issues arising from redundant staff.

The factors that influenced the design of prevention and control programmes included:

• the access of affected population groups to, and coverage provided by, the rural health service and public sector hospitals

• the availability and technical skills of the staff in those facilities

• the management capacity of the health services

• the clinical nature of the diseases in question, which partly influenced how and when those who were affected made contact with health services

• the epidemiological characteristics of the diseases in question, for example, the mode of transmission, the types of vectors and their habits, and the habits and lifestyles of human population groups

• the availability of effective and affordable technology or medical products to address the diseases

The initiatives for preventing and controlling CDs during this period could be categorised in three groups:

1. 1. No dedicated ‘programme’, for example, waterborne diseases, such as endemic cholera, typhoid and paratyphoid.

2. 2. National programmes (or campaigns) with dedicated organisational entities for planning, training, monitoring and evaluation but service delivery through the mainstream health services. Examples are the vaccine-preventable diseases of childhood and TB.

3. 3. National- or state-level programmes with dedicated management structures as well as service delivery mechanisms. Examples include vector-borne diseases such as malaria and filariasis.

Table 6.1 illustrates the key features that differentiated the various degrees of verticality in the spectrum of vertical programme designs.

Dedicated vertical programmes were suited for diseases that required the delivery of medical care (immunisation, diagnostic, medication) to specific target population groups or measures aimed at disrupting the lifecycle of specific vectors. In contrast, waterborne diseases required environmental control approaches coupled with surveillance and outbreak control. Therefore, instead of a dedicated disease-specific vertical national programme, preventing waterborne disease was the responsibility of environmental health services (see Chapter 7), while surveillance and control of disease outbreaks was the purview of mainstream health services for CD epidemiology and control.

6.3 The Next 30 Years: The Era of the Integrated/Horizontal Approach to Disease Control (Mid-1980s to the Present)

6.4 Conclusion

Malaysia has successfully reduced the burden of several CDs through time-limited dedicated programmes aimed at specific diseases. These programmes largely avoided the well-known disadvantages of vertical programme approaches. There are several contributing factors: programme designs recognised and relied on the existing and developing healthcare delivery system. Thus, at the front line, service delivery was in the hands of the PHC providers.⁵ This avoided unnecessary duplication and inefficiencies and subsequent potential redundancy and wastage of human resources and physical facilities. On the other hand, the dedicated vertical approach enabled the development of competencies in programme management, supervision, monitoring and evaluation that later transferred to the public health sector. Conceivably, reliance on domestic and not foreign funding ensured that programme design was accountable to domestic authorities and therefore aligned to national health and development priorities and strategies. (Other chapters elaborate on these priorities and strategies.)

Emerging and re-emerging infectious diseases pose continuing challenges, some of which have been easier to address. The underlying factors are the adaptive behaviour of pathogens, changes in the habits and immune levels of communities that expose them to virulent pathogens, and changes in the environment that facilitate change in either pathogens or humans. There is insufficient knowledge on how the emergence of a new disease can be prevented. Therefore, health systems rely on rapid recognition and effective control of outbreaks. Quick to recognise that Malaysia has the climatic and geographic features that place it at risk of emerging diseases, particularly those arising from zoonotic pools of infection (Ministry of Health, 2002; 2004), the country rapidly developed the capacity for early recognition and containment of outbreaks (Reference LimLim, 1999). There has been less success in dealing with re-emerging diseases caused by human behaviour such as migration and drug use or by the adaptive behaviour of pathogens and vectors compounded by human behaviour, such as antibiotic-resistant microbes and dengue.

Malaysia has had less success in the field of NCDs. The reasons for this are unclear. The range of diseases is much broader and their causative and contributory factors more varied. For some, such as several neoplastic diseases, medical knowledge about their prevention and management is limited. For others, such as cardiovascular and metabolic diseases, the contributory factors require a change in human behaviour, which is complex and dependent on a wide variety of influences. The health sector has yet to devise effective means of addressing many of those influences.

6.5 Key Messages from Malaysia’s Experience

7.1 Introduction

The protection and management of the natural and built environment and monitoring its relation to and impact on health are important components of any country’s health system. The ever-expanding global population and increasing urbanization place a strain on the environment and create new risks and exposures that exacerbate health problems. The first line of defence in disease prevention is controlling the physical, chemical and biological agents in the environment that have the potential to affect populations. Thus, every aspect of the environment that impacts on health falls within the scope of environmental health services (EHS). Clean water, safe disposal of solid waste and wastewater, vector and rodent control, air pollution control, food quality control and climate change are just some examples. In this chapter, we focus on providing a broad overview of the evolution of EHS in Malaysia as part of the overall health system.

7.2 Overview of EHS and Its Evolution in Malaysia

In the 1960s, after independence, 70% of the population was poor and resided in rural areas (see Chapter 3). Limited water accessibility and communicable diseases were major problems, which were addressed by the Rural Environmental Sanitation Programme (RESP), an integral component of the Rural Health Services (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). Highly effective community mobilization by allied environmental health officers and technical expertise from engineers trained in public health are credited as two success factors of the RESP, which achieved high levels of coverage and drastic reduction of the disease burden from waterborne diseases.

With increasing economic development, more than 70% of the population moved to urban areas, life expectancy increased, and there was a decline in infant mortality rates and incidence of communicable diseases (see Chapter 3) (Ministry of Health Malaysia, 1988–2017). However, population growth, increasing urbanization and industrialization introduced other environmental hazards, creating the need to address a wider range of environmental health issues such as sewerage, water quality, solid and hazardous waste, and radiation protection.

EHS in Malaysia began in an organized and structured manner with the establishment of the Environmental Health Engineering Programme in the Ministry of Health (MoH), pioneered by engineers seconded from the Public Works Department (PWD) in the 1970s. This pool of engineers, often assisted by sanitary engineers from the World Health Organization (WHO), went on to strengthen the EHS as an integral part of the MoH’s public health programme.

As the Constitution of Malaysia apportions responsibility for health to the federal government, and water supply and urban sanitation to state and local governments, the responsibility for managing EHS was split among different government agencies (see Chapter 12).

To provide leadership and the relevant authority, some public health engineers were seconded from the MoH to some of these departments. Thus EHS in Malaysia grew primarily because of the leadership and governance role the MoH took. EHS established an organizational structure and staffed it with trained personnel while at the same time empowering the organizational units with the required funding. The initial batch of public health engineers provided the leadership on the ground to support the health inspectorate and health officers. Human resources training and development were crucial to achieving success. Environmental health was introduced into postgraduate public health programmes. Engineers who had training in public health helped to upgrade the training of health inspectors and health overseers. The upgraded three-year course for health inspectors (see Chapter 8) included aspects of newer technologies in wastewater treatment, water treatment and waste disposal. Also, environmental health was included in the training of microbiologists and biochemists. Expertise was shared with other ministries and departments. The WHO contributed by establishing the Centre for the Promotion of Environmental Planning and Applied Studies (PEPAS), which conducted valuable research and training programmes that in turn led to policy and programme formulation such as the National Solid Waste Management Strategy (WHO Western Pacific Region, 1977). Introducing health impact assessment (HIA) to other agencies for development projects was a concerted effort using many existing channels available at the state and federal government levels (Reference Hashim and HashimHashim & Hashim, 2009).

7.3 Key Messages from Malaysia’s Experience

8.1 Introduction

This chapter explores how the Malaysian health workforce evolved over a 60-year period. It analyses the dynamic interactions between various forces in the health system and explores how broader societal elements such as education levels and economic growth; evolving epidemiological, demographic and behavioural patterns; and macroeconomic policies contributed to the dynamic interactions and influenced the subsequent outcomes for the health system.

This chapter does not attempt to provide a detailed profile of the Malaysian health workforce, as such information is available on the websites of the Malaysian Ministry of Health (MoH) (Ministry of Health Malaysia, 2016b) and the World Health Organization (WHO) (World Health Organization, 2014).

8.2 Post-independence: The Early Phase (1960s and 1970s) – Focus on Improving Access

During the years immediately after independence, the Malaysian population was largely rural and had relatively low literacy and high rates of maternal and infant mortality, vaccine-preventable diseases, malaria, tuberculosis, water- and soil-borne disease and malnutrition (see Chapter 3). The economy was doing well, with a steadily increasing gross domestic product (GDP). Guided by strong political considerations, the government implemented policies for rapid integrated rural development, focusing on infrastructure, education and healthcare (see Chapter 3). A nationwide rural health service developed rapidly (see Chapter 4), together with vertical disease control programmes for malaria, tuberculosis, filariasis, yaws and various food-, water- and soil-borne diseases (Chapter 6). Community mobilisation was a key feature of the development process. Table 8.1 summarises key drivers shaping the development of the workforce at this time.

The rapidly expanding rural health programmes needed large numbers of healthcare workers close to rural communities. The interventions they needed to deliver were not too technically complex. The MoH concentrated on rapidly producing large numbers of allied health personnel (mainly nurses of different categories) to populate the rural health services. At this juncture, the government did not attempt to rapidly increase the number of doctors (Table 8.2). Several considerations underpinned this policy. First, entry competence for basic training was lower for allied health personnel than for doctors, so allied health candidates were more readily available, given the literacy levels at that time. Additionally, allied health personnel were more affordable. The challenge was to ensure the production of sufficient numbers of health personnel with the skills and competence to provide safe and effective care. To address this, training institutions for allied health personnel were placed under the control of the MoH rather than in universities under the Ministry of Education (MoE). At that time, the sentiment was that universities were too distant from the front-line of healthcare delivery and would focus on academic measures of excellence rather than the practical skills needed at the front-line. Box 8.1 summarises the critical features of the training programmes. Training institutions were confined to the public sector, enabling the MoH to co-ordinate production with subsequent employment and deployment in the rapidly expanding public sector services. Another feature was that domestic funding, and not foreign aid, supported the training programmes. Foreign assistance was mainly of a technical nature (Box 8.1).

Training programmes expanded rapidly for allied health personnel, namely midwives and health nurses (for MCH and nutrition), public health overseers and health inspectors (for environmental sanitation), and medical assistants and pharmacy assistants (for treating common illnesses) (Table 8.2).

In contrast, during this phase of development, the production of doctors, dentists and pharmacists was limited. For example, during the 20-year period 1955–1975, the number of nurses and assistant nurses/midwives increased at a much faster rate than that of doctors (Table 8.3).

Courses that provided the basic qualification for doctors were available only in three local universities, and the number of places was severely limited. No post-graduate training was available, and there was a limited number of scholarships for specialist training in foreign countries (mostly in the UK). During these earlier years, expatriate staff on short-term contracts filled key vacancies in medical officer and specialist positions until local staff became available and replaced them.

As a result of the rapid recruitment and training of nurses and midwives, the number of people per nurse/midwife declined about four-fold from 2,488 in 1964 to 570 in 1980 (see Chapter 3: Supplementary Table 3.L). The number of people per doctor also declined by about half from 7,145 in 1960 to 3,563 in 1980 (see Chapter 3: Supplementary Table 3.K).

Several governance mechanisms controlled the quality of health personnel (World Health Organization, 2014). First, legislation mandated that qualified personnel in core categories such as doctors, dentists, pharmacists, nurses and midwives had to be licensed to practice and were placed on registers. This served to control unqualified, illegal practitioners. Second, as the public sector was by far the largest employer of health personnel, their employment conditions were governed by civil service rules and regulations that also defined their financial and non-financial benefits such as medical care, travel subsidies, highly subsidised housing, employment security and pension benefits. Thus the public sector was able to control the composition and quality of the health workforce.

The health system outcomes relevant for assessing this early phase of development include availability of and access to health staff, utilisation of services, and selected mortality and morbidity indicators closely associated with the performance of the health workforce. Data for nurses/midwives suggests that increased availability was associated with utilisation and health status (Table 8.4) (trend data for other categories were not available).

8.3 The Second Phase of Development (1980s–1990s)

Several overarching features influenced development during the 1980s and 1990s. Rapidly rising female literacy and rural-to-urban migration contributed to the evolving morbidity and mortality patterns (see Chapter 3). Communicable diseases (CDs) declined, while non-communicable diseases (NCDs) became more common (see Chapter 6). As long-established vertical disease control programmes (malaria, tuberculosis, leprosy) merged with primary care (Chapter 4), their staff were absorbed and, where necessary, re-trained to provide a broader range of services. Larger hospitals that offered treatment facilities were overcrowded while smaller district hospitals were underutilised, catering mainly for normal childbirth and ambulatory care for less complex conditions (Public Health Institute, 1983). The bypassing of clinics and district hospitals by patients in favour of larger or more sophisticated facilities for inpatient and ambulatory care was a significant pattern in health care utilisation at this time (Chapter 5). This phenomenon illustrated the growing demand for higher levels of clinical and technical services that came with rising socio-economic and educational status in the population. Table 8.5 summarises the interactions that influenced the evolution of the health workforce at this time.

Staff with higher levels of competence were needed. Several new categories of personnel were recruited. For example, public health engineers were recruited to complement health inspectors (Chapter 7) and pharmacists to complement pharmacy assistants (Chapter 10).

Categories of staff such as nurses, medical assistants and health inspectors attending training programmes in the public sector received living allowances and accommodation during their training period. The health personnel training programmes profile of 1975 provides an insight into the evolutionary process of the workforce. The training of nurses and assistant nurses was at a peak; midwives were being converted into community nurses, health inspector training was upgraded and pharmacist training had just begun (Table 8.6).

Meanwhile, growing prosperity encouraged the growth of private sector healthcare. This was associated with the continuing challenge of the brain drain of doctors, particularly those who were more experienced and specialist, from the public sector to the private sector (Ministry of Health Malaysia, 2016b). Although the production of doctors increased during the 1980s and 1990s, a sizeable proportion moved from the public to the private sector after the mandatory period of public sector service. Thus the ratio of public-to-private sector doctors remained about 50:50 (Figure 8.1). According to an analysis by Reference Hameed MusafarHameed Musafar (2014), the major contributory factors of this brain drain were the slowing of wage growth in the public sector combined with the rapid increase of private hospitals and beds, where doctors had better remuneration and working conditions.

Figure 8.1 Malaysian doctors in the public and private sectors, 1955–2013.

Sources: Calculations by the author derived from data from the Ministry of Health Malaysia (1971; 1974; 1982; 1983; 1984; 1986; 1995a; 2000; 2010) and the Government of the Federation of Malaya (n.d.).

The shift of doctors from the public to the private sector also created regional disparities. The West Coast states of Peninsular Malaysia experienced much faster socio-economic development than the East Coast states and the states of Sarawak and Sabah¹ (see Chapter 3), thus private sector healthcare was concentrated in the West Coast states, where patients could pay for these services (Figure 8.2). Consequently, the health sector faced the dual challenge of addressing brain drain to the private sector and inequitable access to healthcare between the regions.

Figure 8.2 Regional disparities in availability of doctors, 1970–2010.

Sources: Calculations by the author derived from data from the Ministry of Health Malaysia (1971; 1974; 1982; 1983; 1984; 1986; 1995a; 2000; 2010) and the Government of the Federation of Malaya (n.d.).

Several policy responses targeting health sector development emerged to address these challenges. One was the national drive to balance the inequitable development that had seen the West Coast states progress much faster than the other states (Prime Minister’s Department, n.d.b). Faster development of the less-developed states was expected to facilitate the growth of the private sector, including the private healthcare sector. Another policy was to improve managerial skills in the public sector for better efficiency (obtaining more and better outputs for the inputs) (Prime Minister’s Department, n.d.a). Better in-house personnel management was expected to address some of the frustrations of the higher-level categories in the public hospitals. A third approach was to leverage the scarce resources of skilled clinical specialists in the public sector by upgrading the competencies of healthcare workers and encouraging the adoption of a team approach by clinical specialists working together with other categories of healthcare workers. Internal MoH policies on staff placement continually struggled to increase numbers in the less-developed states. These policies resulted in changes in the health workforce profile.

Clinical competencies were upgraded through curricula changes. Some allied health professional categories were upgraded to acquire broader competencies and better remuneration, while others were phased out (Box 8.3). Simultaneously, nursing training was broadened and opened to private sector training institutes. These strategies resulted in a rapid increase in the nursing workforce. As a result, the number of people per nursing personnel was reduced from 1,879 in 1970 to 481 in 1990 (Table 8.7).

The local production of physiotherapists, occupational therapists and radiographers also increased rapidly (Table 8.2). Improved school enrolment and positive discrimination measures enabled rural students to acquire secondary education and resulted in larger numbers of better-qualified candidates for these courses. To improve managerial efficiency, doctors who occupied managerial positions at district and state levels received specialist post-graduate training in public health, while those with managerial positions in hospitals attended purpose-designed in-service management courses (Box 8.3). The establishment of new medical schools accelerated the production of doctors (Table 8.3); specialist training for doctors and for nurses was enhanced.

Various measures were introduced to redress the geographic imbalance in distribution (e.g. special allowances and housing, access to specialist training) and also to stem the brain drain to the private sector (e.g. compulsory public sector service for specified periods). However, as illustrated in Figure 8.1, the proportion of doctors in the public and private sectors did not change until the end of this period. The flow to the private sector was merely contained and not reversed. Also, although the availability of doctors improved steadily, the gap between the West and the East Coast states of Peninsular Malaysia narrowed only after 1995, while the gap with East Malaysia remains challenging even today (Figure 8.2).

Systemic factors driving individual and collective choices have contributed to the persistence of the gap. Doctors in East Malaysia face more difficulties in accessing facilities such as education for children and entertainment, as well as distance from extended families (Ministry of Health Malaysia, 2016b). Additionally, both public and private hospitals are in places with higher population density for economies of scale; with doctors and medical staff of other higher categories concentrated in hospitals, the pursuit of efficient resource use inadvertently contributes to inequalities. Finally, private hospitals are concentrated in more prosperous regions, where the community has the ability to pay for services. These factors jointly create conditions for the inequitable distribution of human resources, and especially of doctors.

The challenges of regional inequalities notwithstanding, overall access to healthcare has increased, with a significant proportion of this increase resulting from private sector expansion (Table 8.8), and utilisation has increased along with access (Figure 8.3).

Figure 8.3 Utilisation of outpatient services in Malaysia.

Source: Reproduced from Health Policy Research Associates et al. (2013).

8.4 The Third (Most Recent) Phase of Development (2000s through to 2017)

After the turn of the century, macroeconomic policies focused on achieving ‘developed country status’ by 2020, which included eradicating poverty and redressing imbalances, building a knowledge-based society and strengthening human resource development with higher levels of knowledge, technical and thinking skills (Economic Planning Unit, n.d.). Globalisation and information communication technology increased, as did urbanisation (62% in 2000) (Department of Statistics, 2001). Lifestyles changed, particularly in relation to food and exercise habits (Reference LimLim, 2016; Koh et al., 2015), and migration increased (an estimated 0.23% of the population) (Department of Statistics Malaysia, 2019), with a sizeable proportion of undocumented migrants. All these forces impacted on the health status of the community (see Chapter 3). While the prevalence of NCDs was rising rapidly, some CDs re-surfaced (tuberculosis and dengue) while new threats emerged (HIV/AIDS, severe acute respiratory syndrome (SARS)) (see Chapter 6). Meanwhile, public expectations of health services also increased, influenced not only by rising economic and education levels but also by readily accessible information through electronic connectivity (see Chapter 3).

Medical technology in clinical, imaging and laboratory sciences developed rapidly, bringing with it demands for more varied and higher levels of competencies in the health workforce. These demands on the health services were mirrored by demands from the health workforce for better recognition, higher levels of education and better wage scales. Table 8.9 illustrates how different socio-economic changes at that time influenced the evolution of the health workforce.

A confluence of pressures from socio-economic forces, population behaviour, technological advances, and demands from health service delivery and the health workforce resulted in changes in three related but distinct developments in human resources for health, namely:

1. 1. Basic (pre-employment) education programmes for health and allied health professionals increased their entry requirements and became more focused on achieving defined exit competencies, replacing the earlier implicit and often vague academic standards. A wide range of education programmes for health personnel that hitherto had been under the purview of the MoH were transferred to universities and colleges under the purview of the MoE so that they could have diploma- or degree-level qualifications that commanded higher remuneration packages.

2. 2. A wider range of categories of health personnel, particularly allied health personnel, was produced and employed. By 2014, there were 31 categories of allied health professionals employed by the MoH (Ministry of Health Malaysia, 2016b). They required relevant governance mechanisms (qualification standards, practice regulations, remuneration packages, career pathways) (World Health Organization, 2014).

3. 3. Demand for specialists increased, bringing with it challenges in ensuring standards of quality, appropriate remuneration, distribution and access. This in turn gave rise to the need for managing standards for quality (specialist registers, accreditation, credentialing and continuing education) and remuneration packages (World Health Organization, 2014).

Dichotomies between the health and education sectors and between the public and private sectors in education and health were major structural challenges that affected all the above three aspects of development, which in turn constrained health service delivery. The education sector produced health personnel, while the health sector utilised them. There was a dichotomy in the vision and motivations of education and health between the public and private sectors. In both education and health, the public sector focused on societal expectations within tightly controlled budgets and the private sector on commercially viable and competitive enterprises. Box 8.4 summarises the Malaysian experience.

8.5 Workforce Performance

The performance of the health workforce is intimately related to its equitable distribution and utilisation, client satisfaction and quality of healthcare. This sub-section provides information on selected indicators of the performance of the workforce.

8.5.1 Equitable Distribution

Specialist doctors are the most expensive category of healthcare worker and the category for which equitable distribution is the most difficult to achieve. The distribution of selected illustrative key specialist doctors in 2013 was, as expected, highest in the West Coast states of Peninsular Malaysia, but there was a much smaller difference between the Peninsular East Coast states and East Malaysia (Figure 8.4).

Figure 8.4 Distribution of selected specialist doctors in Malaysia, 2013.

Source: Ministry of Health Malaysia, 2016b.

8.5.3 Satisfaction

Human resources play a large role in determining client satisfaction with healthcare services. The community perception module of the 2015 National Health and Morbidity Survey obtained user satisfaction scores on several aspects of services in clinics and hospitals in the public and private sectors. In terms of provider behaviour, more than 70% of users of clinics and hospitals recorded satisfaction levels of ‘good’ or ‘excellent’ in terms of ‘ability to give diagnosis and treatment’, ‘give clear explanations’ and ‘courtesy and helpfulness’. There was little difference between the satisfaction levels reported by users of public and private facilities (Figures 8.5 and 8.6). However, among the other aspects of care, the main source of dissatisfaction regarding public sector clinics and hospitals was waiting time, whereas that for the private sector was treatment charges (Figures 8.5 and 8.6).

Figure 8.5 Reported satisfaction with public and private clinics, 2015.

Source: Institute for Health Systems Research, n.d.

Figure 8.6 Reported satisfaction with public and private hospitals, 2015.

Source: Institute for Health Systems Research, n.d.

8.6 Conclusion

In the Malaysian experience, the evolution of the health workforce was determined by the demands of the evolving service delivery system and the capacity of educational institutions, both local and foreign, to produce health workers. As noted in earlier chapters, the evolution of service delivery patterns was influenced by evolving socio-economic status, demographic profile and morbidity and mortality in a community. In parallel, educational status and evolving socio-economic status influenced the evolution of educational institutions. This interaction between demand and supply was moderated by financing and governance measures that evolved over time in recognition of the competing pressures from the larger ecosystem on the demand for and supply of health workers.

Governance and financing mechanisms flexibly shaped the health workforce in response to demands from the health services as they evolved in response to population and health demands.

Legislation required registration and annual licensing for practice key professions, resulting in:

• control of unqualified practitioners, and

• standards for practice defined by recognised qualifications and sources of qualification.

Education standards for curriculum and quality were enforced during:

• the earlier phases – through licences and recognition only of institutions only in the public sector (mainly the MoH), and

• the later phases – through a regulatory authority (the MQA).

Financing of students for training has mostly been from the government for study at local public and private institutions and foreign institutions. This largely facilitated the government’s management of the composition, numbers and quality of the health workforce.

Employment: Being the major employer, the public sector can set standards regarding wage structure and benefits packages. However, in the case of specialist doctors, where demand exceeds supply, pressures from the private sector created the necessity for the public sector to upgrade its benefits package.

Foreign inputs have been used strategically to develop and support local resources:

• Monetary aid has been negligible.

• Technical input is used strategically to design curricula, train trainers and set standards.

• Expatriate staff have been very few, mainly for working in rural areas during the earlier years and to provide specialist skills while awaiting the development of local expertise.

The composition of the workforce contributed to the development of an affordable health system.

• Nurses were the backbone of the rapidly developing rural health service that responded effectively to conditions of high maternal and infant mortality (Reference Pathmanathan, Liljestrand, Martins, Rajapaksa, Lissner and de SilvaPathmanathan et al., 2003) and remain the dominant category in the health workforce. They far outnumber doctors.

• ‘Task shifting’, although not acknowledged formally, has been practised throughout all phases of development in accordance with specific service needs. Anecdotal evidence suggests that it was associated with focused on-the job training (e.g. procedures in and anaesthesia by medical assistants, emergency obstetrics by nurse-midwives in hard-to-reach locations, and renal dialysis by nurses).

• Education programmes aim to build competence, particularly among nurses and doctors specialising in public health, to manage health programmes and respond to health behaviour that is influenced by the patient’s cultural and personal beliefs.

Alignment of educational curricula with the competencies required in the health sector has been achieved through effective institutional mechanisms. However, the reliance on the public sector to provide almost all facilities for acquiring clinical skills is a major impediment.

The higher categories of healthcare workers undergo relatively long and expensive training. The time lag between entry to an education programme and entry into the workforce could range from 4 years for courses of shorter duration to as long as 10–12 years for doctors. The health sector is unable to predict and prepare for large changes in the quantity or quality of entrants into the workforce, because institutional mechanisms are weak in terms of:

• providing timely information on the numbers and types of graduates the health sector can expect in forthcoming decades, and

• joint strategic planning between the two sectors to adjust production to the capacity for utilisation.

The result is an imbalance between production and absorption capacity and between production and health sector requirements. When the health sector had control over both production and utilisation, the two could be managed through relatively simpler governance mechanisms. With the evolution of systems, much more sophisticated and time-sensitive mechanisms are needed to generate information and co-ordinate policies and policy implementation tools.

The outcomes of this interaction between the supply and demand of healthcare workers impacts on the access, quality, satisfaction and safety of healthcare, which in turn impacts on the morbidity and mortality in the community.

8.7. Key Messages from Malaysia’s Experience

9.1 Introduction

How a country chooses to finance health care for its people is an important indicator of the value it places on health as a public good. A country that relies predominantly on public funding for health care reveals a strong commitment by the state to ensure its people’s access to care.¹ The growth of private funding for health care, particularly when it results in out-of-pocket payments (OOPPs)² for households, is a real risk for financial impoverishment.

A country’s history plays a major role in shaping its health system (Reference PhuaPhua, 1989). Some former British colonies in Asia, for example, have retained many welfare-oriented features of the British National Health Service. These include minimal user fees or even free services at the point of use. However, history cannot be the sole reason for current systemic failures in health. Health systems do not remain static but evolve in response to challenges to their resilience. The state is beholden to ensure through good governance that such transformations meet the changing health needs of its people.

What, then, is the situation in Malaysia? Reliable historical estimates of national health expenditure are not fully available. However, it is known that although health care in the country has been mainly financed using public funds since 1997, the share of public funding just barely exceeded that of private funds for health (Ministry of Health Malaysia, 2019, p. 26). This is in contrast to the situation in 1983, just slightly more than a decade earlier, when the share of public funding was more than 75% of the country’s health expenditure (Westinghouse Health Systems, 1985, p. 4).

By 1997, not only had private funding of health care reached almost half of the country’s health expenditure, this private funding was also mainly composed of OOPPs (Ministry of Health Malaysia, 2019, p. 40). Coincidentally, the 1980s also marked the start of the period when the private provision of health care in the country began a rapid upward trajectory (Reference Chee, Barraclough, Chee and BarracloughChee & Barraclough, 2007, p. 23). Malaysia’s current hybrid health system is one in which the financing and delivery of health care follow the public–private divide – publicly funded public health care providers exist alongside privately funded private health care providers. Over the past few decades, the private health system has expanded at a faster rate than its public counterpart, with consequences not just on the trends but also on the composition of health financing in the country.

However, the raison d’être of any country’s health financing system is not merely to pay for health care. The system should also ensure that the burden of payment, independent of use, is fairly distributed among the population in a country. In many welfare-oriented countries like Malaysia, this translates to a progressive health payment system where richer households contribute proportionately more from their income than poorer ones (Reference Yu, Whynes and SachYu et al., 2008). In addition, the system should also ensure that health funds, especially public funds, are allocated in a manner that can meet population health needs. Like many other middle-income countries, Malaysia is undergoing an epidemiological transition from communicable to non-communicable diseases (NCDs). To curtail the epidemic of these chronic lifestyle diseases effectively, adequate funding should be allocated to preventive and promotional services, early disease identification, early treatment initiation and, most importantly, sustained delivery of needed care. In the case of NCDs, most of these services can be provided efficiently at the primary care level.

This chapter will tell the story of Malaysia’s changing health financing landscape. It starts with a description of the trends in health financing since the 1980s; not just overall expenditure figures but also an analysis of the different financing sources that comprise public and private health financing. This section will also include a brief review of allocative efficiencies in terms of spending patterns according to the categories of services. As financing sources are intricately linked to how health care providers are paid in Malaysia, the narrative will also outline a discussion on the changes within the health care delivery system, the forces at work behind these transformations and the eventual impact on health care financing in this country. The chapter will end with a review of the challenges facing health care financing and a discussion of the way forward for Malaysia.

9.2 Trends in Health Care Financing in Malaysia

The work involved in estimating national health expenditure is not only data-intensive but also has to be conducted in a systematic manner following internationally accepted accounting frameworks to facilitate comparability across time and countries. Efforts to develop the Malaysia National Health Accounts (MNHA) (Box 9.1) to routinely capture the totality of financing flows within the Malaysian health system only started in 2001, and to date, MNHA has produced a series of national health expenditure estimates spanning 1997 to 2017 (Ministry of Health Malaysia, 2019, p. 24). Despite the lack of such accounting systems in the years prior to this, it is still possible to obtain an understanding of the public–private mix of health financing in the country from government documents and reports.

The Malaysian government disseminates policy directions for national development in a series of reports known as the Malaysia Plans, reviewed and updated every five years. The First Malaysia Plan, covering from 1966 to 1970, focused on national priorities during the early years after the birth of Malaysia, and the country is currently in the Eleventh Malaysia Plan period (2015–2020). These reports detail achievements in various economic or social sectors, including health, in the preceding five years before going on to lay down the government’s policies for the following five years. The reports also detail the financial allocations that the government has committed towards the implementation of the policies. The health chapter contained in the Fifth Malaysia Plan (1986–1990) was pivotal. While the first four reports were essentially a re-telling of government priorities to increase public investment in the public health sector, especially to expand access to rural health services (Malaysia, 1966; 1970; 1976; 1981), the Fifth Malaysia Plan was the first to acknowledge the growing financial burden on the government such that ‘programmes for health services under the Fifth Plan will take into account the limited financial capacity of the public sector as well as the need to expand the health care system’, and it noted the need to seek out new sources of health financing, including increased cost sharing with the community to ensure that ‘those who can afford to pay bear a larger share of the cost burden’ (Malaysia, 1986, p. 514).

It was apparent that concerns over the government’s ability to sustain public funding of health care using revenues from general taxation grew in the period of the Fourth Plan. This led the government to initiate the Health Services Financing Study (HSFS)³ in 1983 to review the performance of the overall Malaysian health system and to provide recommendations for alternative financing methods for Malaysia (Westinghouse Health Systems, 1985, pp. 1–10). As part of the work, the HSFS estimated that, in 1983, Malaysia spent $1.8 billion⁴ or 2.8% of the gross national product (GNP) on health (Westinghouse Health Systems, 1985, p. 165). The HSFS noted that 76.6% of this amount was spent on public health care services delivery and that these funds came mainly from general taxation. Full understanding of the estimated private sector expenditure has been difficult, as a full description of the funding sources was not provided. However, the report noted a ‘direct payments’⁵ component that may refer to OOPPs in households (Westinghouse Health Systems, 1985, p. 165). The OOPPs for households in 1983 was estimated at 18.8% or nearly a fifth of the entire country’s health expenditure.