Dr.+safurah+ +health+sector+reform+of+primary+care+towards+1 care

1Care for 1MalaysiaPrimary Health Care

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Benefits 1CARE 1. Achieving enhanced universal coverage2. Integrating public and private sectors 3. Ensuring an affordable and sustainable health care system

for Malaysians4. Providing equitable (in terms of access and financing),

efficient, and higher quality services; and better health outcomes for the Nation

5. Developing effective safety nets for the risk protection of vulnerable groups

6. Remodelling the health system to become more responsive to population needs

7. Enhancing client satisfaction 8. Promoting personalised and better managed care for the

individual and family9. Reducing the brain-drain of skilled personnel both

internally and internationally

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1. Achieving enhanced universal coverage

•Every member of the population is registered (looked after) by a Primary Health Care Physician

•Urban and Rural

•All members of the population

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2. Integrating public and private sectors

•GPs and FMS will be integrated as one Primary Health Care Physician group

• In KKs public sector 1000 vs 3000 post

•200 plus 7000 GPs

3. Ensuring an affordable and sustainable health care system for Malaysians

•No payment at point of care

•Capitation : promotes preventive services and wellness and early case management

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4. Providing equitable (in terms of access and financing), efficient, and higher quality services; and better health outcomes for the Nation

•Capitation

•Benefit package from womb to tomb

•Pay for performance

5. Developing effective safety nets for the risk protection of vulnerable groups

•All members of the population▫ Rich covers the poor▫ Healthy covers the sick▫ Young covers elderly

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6. Remodelling the health system to become more responsive to population needs

•Health Package meeting needs of the population

•Covers all member of the population close to their home

•Providers of their choice

•Autonomous

•Risk sharing with providers

Core component• Restructured health care

delivery ▫ MHDS▫ Autonomous

• New financing mechanism • NHFA

▫ Capitation ▫ SHI

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MOH

• GOVERNANCE & STEWARDSHIP

• POLICY & STRATEGY FORMULATION

• STANDARD SETTING• REGULATION &

ENFORCEMENT• MONITORING &

EVALUATION• PUBLIC HEALTH• RESEARCH• TRAINING

MHDSSERVICE DELIVERY

•PRIMARY CARE

•HOSPITAL CARE

•OTHER SERVICES

NHFA

Independent bodies-Drug Regulatory Authority (DRA)-Health Technology Assessment (HTA)-Medical Research Council (MRC)-Patience Safety Council-Medical Device Bureau-National Service Framework (NSF) (Quality)-National Health Promotion Board- Food Safety Authority- Others

Professional Bodies-MMC-MDC-Pharmacy Board- Others

Figure 1: Functions Within the Restructured 1Care Health System

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MOH

STATE HEALTH DEPT

DISTRICT HEALTH OFFICE

DISTRICT HOSPITALS

STATE HOSPITALS

HKL & Special Institutions

PUBL

IC P

ROVI

DER

S

NHFA

State NHFA

PHC Board

NET

WO

RK

HEALTH CLINICS

PRIVATE PROVIDERS

PRIVATE PHCP (GPs)

PRIVATE HOSPITALS

SHI

Funding flow NHFA – part of MOH

Governance

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Receivetreatment

Home

Patient

PHCP

Public Private

Admit

Refer

HospitalPublic

Private

Return to referring PHCP

Additional services (Out of pocket or private health insurance)

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Community

Primary-care team: continuous,

comprehensive, person-centred care

Self-help group

Liaison community

health workerOther

Social services

Other

Community mental

health unitConsultant support

TB control centre

Diabetes clinicReferral for

multi-drug resistance

Referral forcomplications

Specialized care

Diagnostic services

CT Scan

Cytology lab

Diagnostic support

Papsmears

Environmental health lab Cancer

screening centre

Women’s shelter

Specialized prevention services

Waste disposal inspection

Mammography

Alcoholics anonymous

Training centre

Surgery

Maternity

Emergency department

Traffic accident Placenta

praevia

Hernia

Trainingsupport

Alcoholism

Genderviolence

NGOs

Hospital

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Primary Health Care Physician PHCP

• Doctors• Solo or group• Independent contractors• Family doctor concept• Gatekeepers• Every individual is

registered to PHCP/ratio/special groups

• Trained medical doctors from accredited institutions

• Registered with the MMC and permitted to practice

• As specialist-National Specialist Register

• Over time only Primary Health Care Physicians are allowed to open a PHCP practice.

• Secondary care specialist -not be registered as PHCPs

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REGISTRATION OF PHCP

• Data base of both PHCP and population : matching population density to supply▫ Gatekeeper▫ Training and accreditation mechanism▫ Mechanism for payment, tracking and

monitoring▫ Mechanism for addressing disruption of

services Relocation Vacation Locum and substitute doctor

▫ Arrangements for with group practices Features to encourage group practices

• Patients▫ reliable mechanism for registering without

duplications▫ register according to residence, work place /

school▫ changing provider

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Population : 116,800Private Hosp. : 0, MOH Hosp. : 1

Population : 36,400Private Hosp. : 0, MOH Hosp. : 1 Population : 96,600

Private Hosp. : 0, MOH Hosp. : 1

Population : 90,600 Private Hosp. : 0, MOH Hosp. : 1






Population : 95,700


Distribution of primarycare doctors

WILAYAH PERSEKUTUAN KUALA LUMPUR & PUTRAJAYA

Daerah Klinik KerajaanBilangan klinik

yang ada Pegawai Perubatan

Klinik Swasta

Wilayah Persekutuan Kuala Lumpur 13 13 943

Wilayah Persekutuan Putrajaya 1 1 8

JUMLAH 14 14 951

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KEDAH

Daerah Klinik KerajaanBilangan klinik yang ada

Pegawai PerubatanKlinik Swasta

Kumpulan Sasar

Pegawai Kerajaan

Pesara Kerajaan Jumlah

Kota Setar 10 8 80 22,062 9,557 31,619

Kulim 9 6 38 6,851 2,980 9,831

Baling 5 4 6 1,330 1,103 2,433

Pendang 3 2 8 3,691 600 4,291

Bandar Bahru 3 2 0 541 456 997

Sik 2 1 3 4,143 345 4,488

Padang Terap 3 3 0 797 613 1,410

Yan 2 2 2 536 481 1,017

Kuala Muda 6 4 1 18,727 6,545 25,272

Kubang Pasu 8 5 1 17,870 2,348 20,218

Langkawi 3 2 11 3,435 483 3,918

JUMLAH 54 39 150 79,983 25,511 105,494

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SARAWAK

Daerah Klinik KerajaanBilangan klinik yang ada

Pegawai PerubatanKlinik Swasta

Kumpulan Sasar

Pegawai Kerajaan Pesara Kerajaan Jumlah

Daerah Betong / Betong 9 0 2 3,361 191 3,552Daerah Betong / Saratok 5 0 1 813 214 1,027Daerah Bintulu / Bintulu 5 0 24 3,103 828 3,931Daerah Bintulu / Tatau 4 0 - 27 17 44Daerah Kapit / Kapit 10 1 1 2,577 151 2,728Daerah Kapit / Belaga 6 0 - 39 37 76Daerah Kapit / Song 5 1 - 69 37 106Daerah Kuching / Kuching 13 3 136 45,287 10,236 55,523Daerah Kuching / Bau 2 0 2 482 404 886Daerah Kuching / Lundu 4 0 2 479 160 639Daerah Limbang / Limbang 4 0 3 2114 372 2486Daerah Limbang / Lawas 9 0 3 994 205 1,199Daerah Miri / Marudi 21 0 1 335 59 394Daerah Miri/Miri 8 3 42 7,810 1,490 9,300Daerah Mukah / Dalat 2 0 - 30 66 96Daerah Mukah/ Daro 8 0 - 756 47 803Daerah Mukah/Matu 6 0 - 77 53 130Daerah Mukah 9 0 3 1,346 280 1,626Daerah Samarahan / Samarahan 6 0 6 2,006 15 2,021Daerah Samarahan / Serian 8 0 3 536 537 1,073Daerah Samarahan / Simunjang 6 0 - 156 89 245Daerah Sarikei / Julau 6 1 8 63 37 100Daerah Sarikei / Meradong 6 1 - - - 0Daerah Sarikei / Pakan 4 0 - 38 5 43Daerah Sarikei 2 1 - 1,771 588 2,359Daerah Sibu / Kanawit 4 0 1 113 146 259Daerah Sibu / Selangau 4 0 - - - 0Daerah Sibu / Sibu 4 2 48 5,137 2,064 7,201Daerah Sri Aman / Lubuk Antu 6 2 - 247 33 280Daerah Sri Aman / Sri Aman 7 1 3 2,484 754 3,238JUMLAH 193 16 289 82,250 19,115 101,365

Benefit package for PHC

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•Child health•Adolescent health•Women’s health •Men’s health•Family planning•Antenatal care •Postnatal care •Elderly health •Prevention /promotive •Curative care

•Diagnostic Services•Radiological•Pharmacy•Pathology

KKs will become Super PHCP Clinic

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Primary Health Care Physician“scope of practice”They are responsible for maintaining optimal health of their ‘registered population’ to provide “essential health package” through:•Screening and health assessment from of “womb to

tomb”•Health promotion and counseling /patient education•Prevention activities (paps smear, immunization …)•Diagnosis / differential diagnosis• Intervention and treatment of common illness and

medical conditions •Careplans , long-term care and follow-up•Referral•Data collection for patient and population analysis•Participate in CPDs / CMEs

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Primary Health Care Physicians“operations”•Registers designated population•Receives reimbursement based on per capita for the

provision of essential services•Collects patients data and submit data and information as

required•Compliance to all standards and guidelines as well as

service targets•Commission secondary care from hospitals for patients

where relevant (at what rate?)•Other services may include :

▫ Emergency services and Call Centres▫ School health Services▫ Rehab Services▫ Flying Doctors Services

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FUNDING & INCENTIVES

•Funding through capitation•Case-mix methodology will be employed•Additional Incentives will be provided for:

• Specialist qualifications• House calls• Additional payments for exceeding stipulated

performance of benchmarks• Funding training and topping up courses• Those working in rural or unpopular locations• Those who treat more chronic patients

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CO-PAYMENT ?

•Co-payments will be nominal•To address abuse / moral hazard and to promote

responsible use of services•Likely services are for medicine and dental

services.•Need to identify range and scope of services like

duration, type and entitlement•Very sensitive issue and require strong social

advocacy •Mechanism for waiver for those who cannot

afford and those with entitlement

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Benefits to the Nation

• Strengthen national unity

• Stimulate the health care market

• Reduces unnecessary dependence on government fund

• Financial safety nets for lower and middle income groups

• Contain the rapid growth in health care cost and inflation

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Benefits to the people

• More access to providers • Care nearer to home• No payment at point of

seeking care (during hardship)

• Vulnerable group better protected

• Quality care• Client satisfaction• Greater health outcomes

for community

Benefits to the Providers

• Bridge gaps remuneration and workload

• Optimize HR both sectors

• Encourage serving in rural areas

• Appropriate level of competency and standard of care

Next agenda •Develop full blueprint within 2y▫Building blocks

Mapping of population & providers Professional & care standards Benefit packages Monitoring & Evaluation

•Phased implementation, evaluation and monitoring

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TOR TWG PHC

1.Study the existing service provision and perform mapping of gaps

2.Develop draft framework for PHC delivery3.Develop phases for implementation▫ awareness and motivation / buy-ins▫ essential universal package▫ standards, accreditation, credentialing

and privileging

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TOR TWG PHC Develop phases for implementation (cont’d) ▫ Health informatics

Registration of providers and population ▫ Registration list of Primary Care Providers to

the Population▫ Propose Organisational and Management

Structure of the various levels ▫ Develop clear roles and relationship of Primary

Care related NGOs & other Organizational Support Systems

▫ Develop indicators to monitor risks or impact

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TOR TWG PHC

4.Perform risk mitigation for each phase▫ Identify, characterize, and assess threats (political and

resources)▫ Assess the vulnerability of critical implications to specific

threats (scope too big or too small, cost too high etc)▫ Determine the risk (i.e. The expected consequences of

specific types of attacks on specific assets)▫ Identify ways to reduce those risks▫ Prioritize risk reduction measures based on a strategy

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SJ /10Mar 2011

1Care for 1Malaysiamandate: PHC : Equity, Universality, Solidarity

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SJ /10Mar 2011

Dr.+safurah+ +health+sector+reform+of+primary+care+towards+1 care

Health & Medicine

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