MEDICAL PROFESSIONAL - Malaysia Productivity Corporation … · iv Foreword In the 10th Malaysia...
Transcript of MEDICAL PROFESSIONAL - Malaysia Productivity Corporation … · iv Foreword In the 10th Malaysia...
RECOMMENDATION REPORT
31 August 2016
MEDICAL PROFESSIONAL
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Contents Foreword ................................................................................................................................... iv
Boxes ......................................................................................................................................... vi
Figures ...................................................................................................................................... vii
Tables ...................................................................................................................................... viii
Abbreviation.............................................................................................................................. ix
Key Points ................................................................................................................................. xii
Overview ................................................................................................................................. xiii
1 About the Review............................................................................................................... 1
1.1 The 10th Malaysia Plan: Modernising Business Regulation ....................................... 1
1.2 What has MPC been asked to do? .............................................................................. 3
1.3 The approach and rationale of this review ................................................................. 5
1.4 Conduct of the study ……………………………………………………………………………………………..5
1.5 Other initiatives by the Governments …………………………………………………………………….8
1.6 Structure of the report …………………………………………………………………………………………..9
2 Overview of the Medical Professionals in Malaysia ........................................................ 12
2.1 History and Development of Healthcare System /Medical Professionals
in Malaysia .................................................................. Error! Bookmark not defined.
2.1.1 Malaysia Plan .................................................................................................... 14
2.1.2 The Plan and Healthcare Professionals Development Policy-Thrusts ............ 15
2.2 The Population, life expectancy and mortality rates of Malaysian .......................... 19
2.3 Health Human Resources .......................................................................................... 22
2.3.1 Healthcare Facilities ………………………………………………………………….. ................... 25
2.3.2 Trends in Health Workforce............................................................................... 31
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3 Best Practice Regulations and Regulatory Burdens ......................................................... 38
3.1 What Is Regulation? .................................................................................................. 38
3.2 Cost of regulation ...................................................................................................... 38
3.3 What are unnecessary regulatory burdens?............................................................. 40
3.4 Sources of unnecessary regulatory burdens ……………………………………...................... 41
3.5 Best practice regulation ............................................................................................ 42
3.6 Medical Professionals’ Issues/Complaints raised by various stakeholders .............. 44
4 Regulations Affecting Medical Professionals in Malaysia................................................ 48
4.1 Regulatory Overview of Medical Professionals in Malaysia ..................................... 48
4.2 Development of the Medical Professional Regulation Framework ……………………….52
4.3 Regulators and Other Related Bodies …………………………………………………………………..62
5 Regulatory Burdens at the Pre-Qualifications and Training of Medical Professionals .. 69
5.1 Inadequate quality control of private colleges providing health sciences
education …………………………………………………………………………………………………………….73
5.1.1 The issues ……………………………………………………………………………………………………..73
5.1.2 Objective of MOHE Act 1996.…………………………………………………………………………80
5.1.3 Objective of MQA Act 2007 ………………………………………………………………………..…80
5.1.4 Options to resolve the issues …………………………………………………………………………81
5.1.5 Recommended option …………………………………………………………………………………..83
5.2 Supplies of clinical training for housemen and nursing graduates in the hospitals are not
sufficient to meet the requirements of the Act ......................................................... 84
5.2.1 The Issue …………………………………………………………………………………….. .................. 83
5.2.2 Options to resolve the issues …………………………………………………………………………92
5.2.3 Recommended option …………………………………………………………………………………..95
6 Managed Care Organization (MCO)................................................................................. 96
6.1 Minimal fees paid to medical professionals ............................................……...….....102
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6.1.1 Minimal fees paid to medical professionals ……………………………………….……..…104
6.1.2 Delayed and partial reimbursement ………………………………………………………….. 108
6.1.3 Intervention on clinics operation ………………………………………………………………. 110
6.1.4 Selective Empaneling and Fee Splitting ……………………………………………………….112
6.2 Objectives of MCOs ................................................................................................. 115
6.3 Options to resolve the issues ……………………………………………………………………………..116
6.4 Recommended option …………………………………………………………………………………..…..120
7 Personal Data Protection ........................................................................................... ....122
7.1 The issues ................................................................................................................ 123
7.2 Objectives of PDPA …………………………………………………………………….……….……………126
7.3 Verification with Regulators ………………………………………………………………….…………...127
7.4 Options to resolve the issues ……………………………………………………………………….. ..... 135
7.5 Recommended option …………………………………………………………….………………………….136
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Foreword
In the 10th Malaysia Plan, the Malaysia Productivity Corporation (MPC) had mandated to
review all regulations affecting the conduct of business in Malaysia with the view to
modernize business regulations. This is crucial in order for the country to move towards its
national aspiration of becoming a high-income nation. Towards this, the MPC has
embarked on a comprehensive review of existing business regulations with the focus on
the 12 NEW Key Economic Areas (NKEA) which have been identified to have high growth
potential.
In this study, the research team led by Zatun, Zuraida and Muhammed Anuar has been
asked to examine the regulatory regimes of the healthcare sector specifically in medical
professionals with the aim of recommending options to remove unnecessary regulatory
burdens.
Through regulation governments can leverage their policy interests on businesses.
Regulation can contribute to a range of social, environmental and economic goals.
However, in practice, some regulations are not well designed and many regulations are
not implemented efficiently or cost-effectively, and some regulations do not even
adequately achieve the ends for which they are designed. Poor regulatory regimes
invariably result in unnecessary regulatory burdens which will stifle business growth.
For this particular study, the focus was on the construction phase up to its completion,
which is the most complex part of the value chain and the most regulated.
The study emulated the approach used by the Australian Government Productivi ty
Commission (AGPC) and the team was guided by a regulatory expert previously from the
AGPC, Ms. Sue Holmes. A comprehensive study of existing regulations governing the
healthcare industry and their regulators was conducted. The regulations were correlated
to the value chain. Engagements with the associations as well as with medical practitioner
that practice in clinic and private hospitals were used in the study. Issues pertaining to
regulations were selected and documented in the study report.
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From these issues and using principles of good regulatory practice, the team then
formulated feasible options for further deliberation. These issues and options are
presented in this report for public consultation with relevant stakeholders in order to
develop concrete recommendations to reduce unnecessary regulatory burdens imposed
by construction regulations.
In the course of the study, the stakeholders including MPC have benefited greatly from
discussions and interviews with various companies, government officials and industry
associations. Valuable input and feedback were received from the AGPC expert, MPC’s
Board of Directors and other interested parties. The MPC is grateful for their assistance
and contributions.
The study was conducted in the MPC Head Office by the Smart Regulation Directorate led
by Mr. Zahid Ismail and overseen by me.
Dato’ Mohd. Razali Hussien
Director General, MPC
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Boxes
Box 3.1: Six Core Principles for Assessing Regulation and its Administration ......................... 42
Box 3.2: Well-Written Regulations .......................................................................................... 43
Box 3.3: Key Indicators of good performances by regulators ................................................. 44
Box 4.1: Employment regulations that may influence HR Practices ………………….………………..48
Box 5.1: MQA Act 2007 ............................................................................................................ 73
Box 5.2: Medical Act 1971……………………………………………………………………………..…………………...85
Box 5.3: A Guidebook for House Officer ……………………………………………………………………………..85
Box 5.4: Nurses Act 1950 …………………………………………………………………………………………………….89
Box 6.1: Private Healthcare Facilities and Services (Private Medical Clinics or Private
Dental Clinics) Regulation 2006 …………………………………………………………………………….104
Box 6.2: Private Healthcare Facilities and Services (Private Hospitals and Other Private
Healthcare Facilities) (Amendment) Order 2013 …………………………………………………..105
Box 6.3: Under the Consumer Protection Act 1999 …………………………………………………………….108
Box 6.4: Competition Act ……………………………………………………………………………………………………110
Box 6.5: Code of Professionals Conduct ……………………………………………………………………………..111
Box 7.1: The Redundancy on Confidentiality of Information …………………………………………….…124
Box 7.2: Personal Data Protection Regulations 2013 ……………………..……………………………………127
Box 7.3: Personal Data Protection Regulations 2010 …………………………………………………………..132
Box 7.4: Disclosures of the information ……………………………………………………………………………...133
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Figures
Figure 1.1: Regulatory Review Framework of MPC .................. Error! Bookmark not defined.
Figure 1.2: Study of Summary Process ..................................... Error! Bookmark not defined.
Figure 1.3: Summary of the Regulatory Issues ……………………………………………………………………11
Figure 2.1: Schematic overview of the health system ............................................................. 13
Figure 2.2: Health expenditure per capita ................................ Error! Bookmark not defined.
Figure 2.3: The Distribution of Government Health Clinic in Malaysia 2013 .......................... 26
Figure 2.4: The Distribution of Private Health Clinic in Malaysia 2011 ................................... 27
Figure 2.5: The Distribution of Government Hospital (MOH) in Malaysia 2013 ………………..…28
Figure 2.6: The Distribution of Private Hospital in Malaysia 2013 ……………………………………….29
Figure 2.7: The Distribution of Public and Private Hospital for each State Malaysia2013…….30
Figure 2.8: Admissions and Outpatient Attendances, 2013…………………………...…………..……....32
Figure 2.9: Public and Private Sector Resources and Workload, 2008 ………………………………...33
Figure 3.1: Issues under review ................................................................................... ………….47
Figure 4.1: The Value Chain of Medical Professional .............................................................. 52
Figure 5.1: The Value Chain of Medical Professionals ……………………………………………………..….70
Figure 5.2: Framework of Accreditation Process …………………………………………………………………72
Figure 5.3: Summary of issues ………..…………………………………………………………………………………..79
Figure 5.4: Statutory Requirement ……………………………………………………………………………………..84
Figure 5.5: Statistics of Housemen from 2011 to 2014 ………………………………………………………..88
Figure 5.6: Summary of issues …………………………………………………………………………………………….91
Figure 6.1: Summary of the Type and Function of MCOs …………………………………………………..100
Figure 6.2: Mode of payment in primary care clinics in 2010 and 2012 ……………………………..102
Figure 6.3: Summary of issues ……………………………………………………………………………………………114
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Tables
Table 1.1: Malaysia’s Competitiveness Performance in the Doing Business Report ........ Error!
Bookmark not defined.
Table 2.1: The health professionals development policies Malaysia Plan .............................. 15
Table 2.2: Population distribution and vital statistics ............................................................ 19
Table 2.3: Health professionals in the public and private secor,2013Error! Bookmark not defined.
Table 2.4: The ratio of health professionals to population, 2008 - 2013Error! Bookmark not
defined.
Table 2.5: Primary care health facilities, 2010......................................................................... 31
Table 2.6: Attrition among Doctors and Dentists in MOH....................................................... 34
Table 2.7: Density of health workforce (per 10,000 population), 2014 .................................. 35
Table 2.8: Seventh Schedule 2006 and Thirteenth Schedule 2013……………………………………...36
Table 3.1: Issues/Complaints raised by various stakeholders ……………………………………………..45
Table 4.1: Roles and description of medical professionals...................................................... 49
Table 4.2: Medical professional and their professional boards …………………………………………..51
Table 4.3: List of Medical Professionals under MOH, Acts, Regulators and APC ………………….51
Table 4.4: Value Chain mapped against Relevant Acts / Regulations ………………………………….53
Table 4.5: Summary of Medical Act 1971 ……………………………………………………………….………….57
Table 4.6: Summary of Nurses Act 1950 (Amendment 1969) and Nurses Registration
Regulation 1985 …………………………………………………………………………………………………59
Table 4.7: Roles and Responsibilities of the Ministry of Health and related agencies
affecting the accreditation and practice of medical professionals …………………….63
Table 6.1: MCOs in Malaysia …………………………………………………………………………………………….98
Table 7.1: Comparison on data protection between Confidentiality Guidelines,
Private Healthcare Facilities and Services Act and PDPA Act……………..………….….130
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Abbreviation
AGPC Australian Government Productivity Commission
AHSP Allied Health Sciences Personnel
APC Annual Practicing Certificate
CCU Coronary Care Unit
CoP Code of Practice
CPC Codes of Professionals Conduct
CPD Continuous Professional Development
DHPCO Division of Health Plan Contracting and Oversight
CSR Corporate Social Responsibilities
DoE Department of Environment
DTF Distance to Frontier
ECFMG Educational Commission for Foreign Medical Graduates
ETP Economic Transformation Programme
EPU Economic Planning Unit
FAIMER Foundation for the Advancement of International Medical Education
and Research
GDP Gross Domestic Product
GLC Government Linked Companies
GP General Practices/ Practitioner
GST Government and Services Tax
HMO Health Maintenance Organization
HEI Higher Educational Institutions
ICU Inensive Care Unit
JCI Joint Commission International
JPA Jabatan Perkhidmatan Awam
Department of Public Services
JTC Joint Technical Committee
LAN Lembaga Akreditasi Negara
National Accreditation Board
MAEPS Malaysian Pharmaceutical Society
MCO Managed Care Organization
MDA Malaysian Dental Association
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MDC Malaysia Dental Council
MERCY Malaysian Medical Relief Society
MITI Ministry of International Trade and Industry
MMA Malaysia Medical Association
MMC Malaysia Medical Council
MOH Ministry of Health
MOHE Ministry of Higher Education
MPC Malaysia Productivity Corporation
MQA Malaysia Qualification Agency
MQF Malaysian Qualifications Framework
MQR Malaysian Qualifications Register
NBM Nursing Board Malaysia
NDPC National Development Planning Committee
NEM New Economic Model
NGO Non-governmental Organisation
NKEA National Key Economic Area
NPDIR National Policy on the Development and Implementation of
Regulations
O & G Obstetrics & Gynecology
OECD Organization for Economic Co-operation and Development
PDPA Personal Data Protection Act
PEMUDAH Pasukan Petugas Khas Pemudahcara Perniagaan
Special Rask Force to Facilitate Business
PHC Primary Health Care
PHFSA Private Healthcare and Facilities Act
PRP Provisionally Registered Pharmacist
QAD Quality Assurance Division
RIA Regulatory Impact Analysis
RIS Regulatory Impact Statement
RMP Registered Medical Practitioner
RURB Reducing of Unnecessary Regulatory Burdens
SL1M Skim Latihan 1 Malaysia
TPA Third Party Organization
WBDB World Bank’s Doing Business
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WFME World Federation for Medical Education
WHO World Health Organisation
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Key Points
1. MPC which has been mandated in Tenth Malaysia Plan to carry out regulatory review
with the aim of reducing unnecessary regulatory burdens on the healthcare sector.
2. The review focuses on five medical professionals in healthcare sector, which are:
i) Doctors
ii) Nurses
iii) Pharmacist
iv) Dentist
v) Midwives
3. For the purpose of this review, the scope will be narrowed down into two main medical
professionals servicing the health industry, which are Doctors and Nurses. Nurses shall
also cover specialised nursing areas including dental nurses and midwives
4. These medical professionals are bound by several federal Acts on matters such as
training, registration, practices, services, and termination.
5. The value chain of the study can be broken down into three major phases: pre-
qualification, general practices (GP)/Specialisation and exit/termination.
6. The Ministry of Health is the regulator that responsible for placement of houseman after
medical student’s graduates form the courses.
7. The three main issues are listed below:
i) Prequalification - quality of colleges providing medical courses and
insufficient supplies of training for medical professionals)
ii) General practices – Lack of regulatory framework on practices of Managed
Care Organisation (MCO)
iii) General practices – Discrepancies between Personal Data Protection Act
2010 and Private Healthcare Facilities and Services Act 1998.
8. Key recommendations for improving the existing regulatory arrangements include:
i) Improve the regulatory requirement for accreditation of private colleges
ii) Reduce regulatory burdens on termination of unqualified houseman
iii) Improve the regulatory framework on Managed Care Organisation (MCO)
iv) Expedite the establishment of Code of Practice (CoP) in healthcare industry.
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Overview
The 10th Malaysia Plan indicated that Malaysia has done well in extending affordable basic
healthcare services to all citizens. Malaysia healthcare system was also highlighted as one
that has been relatively successful in providing equitable healthcare in terms of targeting
public health subsidies towards the poor.
Malaysia inherited a health system from the British upon independence in 1957 but with
services based mainly in urban areas. Malaysian healthcare system had evolved from a
simple single provider system to one of multiple providers which are categorised by public
and private sector providers interacting with one another, as well as, third party financiers.
Each party interacts with each other in the process to maximise their benefits. The
government has provided the major healthcare and healthcare related facilities where all
are financed through central taxation. This situation started to change during the 1980s
due to growing demand for healthcare following rising incomes, urbanisation and the
expansion in the middle classes (Chee & Barraclough, 2007).
Public dental services prior to independence were run by British dentists in the large
hospitals assisted by locally qualified dentists who also visited districts and towns. Further,
the private dental care was provided by about 450 mainly locally trained practitioners.
Pharmacy services in Malaysia came into existence in 1951. In 1955, the numbers of
pharmacist was around 301. To enhance its role The Government Pharmaceutical
Laboratories and Stores were established in 1964 in Petaling Jaya to purchase and
manufacture pharmaceuticals for MOH services. However, the absence of dispensing right
has limited the community pharmacist’s professional roles to deliver pharmaceutical care,
optimize their clinical knowledge and utilize their skills2.
Nursing practice in the pre-war period in Malaya then was carried out by nurses who
received “on the job training”. After Independence, health services became mainly a central
government responsibility with delegation of service delivery through state and district
1 Malaysian Pharmaceutical Society (2016) History of MPS, see http://www.mps.org.my/index.cfm?&menuid=84 2 Mohd A.Hassali, Vivienne M. S. Li, Ooi G. See (2014), Pharmacy Practice in Malaysia, Journal of Pharmacy Practice and Research.
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health administrations3. The first private nursing school in Malaysia was established at
Assunta Hospital, Petaling Jaya.
Current legislative arrangement
Medical professionals being a party within the professional services industry covers the
activities of various Acts governing the professional codes of conduct. Generally, there
are about 150 Acts governing the practice of Medical Professionals.
The main Acts include:
i. Medical Act 1971 (Act 50)
ii. Dental Act 1971 (Act 51)
iii. Nurses Act 1950 (Act 14) & Nurses Registration Regulations 1985
iv. Registration of Pharmacists Act 1951 (Act 371) & Registration of
Pharmacists Regulations 2004
The main objective of the professional Acts is to govern the practise of professionals in the
interest of the public and the nation. However, there are instances where over-regulating
of these professions have led to unnecessary burdens on the practitioners and result in
higher costs or poorer service to the public. Unnecessarily demanding Acts, rules and
regulations need to be reviewed to make accreditation, career growth and practice easier
and to boost the effectiveness of medical services.
Other main Acts that involved in the study are:
a. Private Higher Education Act 555 (1996 amend 2006)
b. Education Act 550 (1996 amend 2006)
c. Malaysian Qualification Agency Act 679 (2007)
d. Malaysia Employment Act 1955
e. Private Healthcare Facilities and Services Act 1998 (Act 586)
f. Private Healthcare Facilities and Services (Private Hospitals and Other
Private Healthcare Facilities)Regulations 2006
3 2013, Western Pacific Region Nursing and Midwifery Databank, available at : http://www.wpro.who.int/hrh/about/nursing_midwifery/db_malaysia2013.pdf
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g. Private Healthcare Facilities and Services (Private Medical Clinics or
Private Dental Clinics) Regulations 2006
h. Personal Data Protection Act 2010 (Act 709)
i. Personal Data Protection (Class of Users) Order 2013
j. Personal Data Protection (Fees) Regulations 2013
k. Personal Data Protection (Registration of Data User ) Regulation 2013
l. Personal Data Protection Regulations 2013
m. Insurance Act 1996
n. Companies Act 1965
o. Competition Act 2010
p. Consumer Protection Act 1999
Reducing Unnecessary Regulatory Burdens on Business:
Medical Professional
1. What the MPC has been asked to do
The 10th Malaysia Plan has mandated Malaysia Productivity Corporation (MPC) to carry out regulatory review in order to make it easier to do business in Malaysia. Towards this end, the MPC has embarked on reviews the existing regulations which have primary impact on the 12 National Key Economic Areas (NKEA). The NKEAs were chosen on the basis of their high growth potential. One of the NKEAs is the Healthcare industry and specifically, Medical Professionals, which is the focus of this study. This review process will draw on the expertise and perspectives of the public and private sectors to help identify key issues and the appropriate solutions.
2. Conduct of the review
The study will emulate the approach used by the Australian Government
Productivity Commission (AGPC) and the team will be guided by a regulatory
expert Ms. Sue Holmes. The team will select a sample of businesses from the
Healthcare sector in Malaysia. The team will interview the Healthcare
professionals and managers in Healthcare Facilities to identify the regulatory
issues of concern. Based on the principles of good regulatory practices, the
team will formulate feasible options for further deliberation. These issues and
options will be subject to further consultation with relevant stakeholders in order
to develop concrete recommendations that will reduce unnecessary regulatory
burdens. The figure below summarizes the study process for this review.
3. Timing
This review commenced in September 2014 and has started with canvasing interested parties about concerns with written regulation and its administration.
Summary of Study Process
4. Contacts Interested parties are welcomed to participate in this review. You can contact the persons below on matters relating to this review. Cik Ilyana Norsaidah Ab Rahman (Administrative matters) Ph: 03- 79600173 Email: [email protected]
En. Mohammed Alamin Rehan (Other matters) Ph: 03- 79600173 Email: [email protected]
Conceptualize the industry
Value Chain and skill mix
List all Acts and map them onto
the Value Chain
Scoping & Target Selection
Develop a list of questions
Conduct interviews
Analyse Information gathered
Draft report (with proposed
options)
Workshops and other feedback
Final Report
LIT
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IN
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(B
ooks; A
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Sta
tistics)
CO
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N A
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EX
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’S A
DV
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(F
rom
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)
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Chapter 1: About the review
1.0 About the review
The regulatory environment has a substantial effect on the behaviour and
performance of businesses. While regulation can help to serve important economic,
social and environmental objectives by addressing market failures, it is crucial that
regulatory interventions do not unnecessarily inhibit private sector participation in the
economy and its contribution to higher standards of living. This requires a regulatory
environment that promotes competition and does not inhibit innovation while also
addressing policy objectives and market failures.
To maximise the innovation and output potential of an economy, firms need clear price
signals and the flexibility to shift resources as conditions change. However, Malaysia
has accumulated many regulations over the years many of which constrain change
and growth. Some regulations also inhibit competition and innovation by creating
barriers to entry to some activities and industries.
1.1 10th Malaysia Plan: Modernising Business Regulation
In 2007, the Government took a significant step in rationalising Malaysia’s regulatory
regime by launching PEMUDAH, a special task force to facilitate business.
PEMUDAH’s substantial achievements include reducing the process of starting a
business from 9 procedures and 11 days to 3 procedures and 3 days, reducing the
time taken to register standard property titles from 41 days to 2 days, and reducing
the time taken for tax refunds to less than 30 days as compared to the previous year
which takes around 1 year.
Based on the World Bank’s Doing Business 2015: Going Beyond Efficiency report,
Malaysia’s standing in the ease of doing business ranking improved from 20 th in last
2014 report to 18th, scoring 78.8 DTF score, 10 points behind Singapore which has
retained its position as the economy with the most business-friendly regulations in the
world.
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To make Malaysia the preferred place to do business, the Government has begun a
comprehensive review of business regulations, starting with regulations that impact
on the twelve National Key Economic Area (NKEAs). Regulations that contribute to
improved national outcomes will be maintained, while redundant and outdated
regulations will be eliminated and replaced with better ones where appropriate. This
review will be led by the Malaysia Productivity Corporation (MPC) in collaboration with
relevant experts from business and academia. This work will complement the efforts
of PEMUDAH and ensure that any reviewed regulations do not result in disincentives
to business, investment and trade.
Table 1.1: Malaysia’s Competitiveness Performance in the Doing Business Report
Rank Year
2010 2011 2012 2013 2014 2015
Ease of doing business 23 21 18 12 20 18
Starting a business 88 113 50 54 12 13
Dealing with construction
permits1 109 108 113 96 39 28
Getting electricity nil nil 59 28 28 27
Employing workers2 61 nil nil nil nil
Registering property 86 60 59 33 74 75
Getting credit 1 1 1 1 19 23
Protecting investors 4 4 4 4 5 5
Paying taxes 24 23 41 15 31 32
Trading across borders 35 37 29 11 10 11
Enforcing contracts 59 59 31 33 30 29
Resolving Insolvency
(Closing a business) 57 55 47 49 65 36
1 The time and cost related to obtaining an electricity connection were removed from the dealing with construction permits indicators and are allocated at the getting electricity indicators 2 The employing workers data are not included in the ranking on the ease of doing business starting from
2011
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1.2 What has the MPC been asked to do?
The 10th Malaysian Plan has mandated the MPC to carry out regulatory reviews with
the goal of making it easier to do business in Malaysia. The review is in line with the
aspiration envisaged in the New Economic Model (NEM) to transform Malaysia into a
developed economy. The NEM strongly indicates the need for good regulatory
management to improve regulatory quality. The 10th Malaysia Plan in Chapter 3 on
Modernising Business states:-
“The regulatory environment has a substantial effect on the behaviour
and performance of companies. Private sector participation in the economy and innovation require a regulatory environment provides the necessary protections and guidelines, while promoting competition”.
Too often, Malaysian firms face a tangle of regulations that have accumulated over the years and now constrain growth. At the same
time, regulations that would promote competition and innovation are absent or insufficiently powerful”. “To achieve this goal, the Government will begin with a comprehensive review of business regulations, starting
with regulations that impact the NKEAs”.
Specifically, the MPC is:
reviewing existing regulations with a view to removing unnecessary rules and
compliance costs. Priority is given to regulations affecting NKEAs
ensuring that regulators conduct regulatory impact assessment for new regulations
making recommendations to the Cabinet on policy and regulatory changes that will
remove unnecessary regulatory burdens and enhance productivity.
The reviews of existing regulation involve public consultation with stakeholders and
interested parties. The process will be implemented with the intention to improve the
quality of existing regulations. Other processes within MPC will focus on ensuring the
good quality of new regulation particularly by applying regulatory impact analysis.
This report reviews existing regulation affecting two main medical professionals
servicing the health industry, which are Doctors and Nurses. As shown in the Figure
1-1, the review process takes into account both government and business
perspectives as well as reports, data and reasoning of organisations such as the
World Bank, the World Health Organisation (WHO) and the Australian Government
Productivity Commission (AGPC).
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Figure 1.1 Regulatory Review Framework of MPC
PEMUDAH: Special Task Force to Facilitate Business
NDPC: National Development Planning Committee
WBDB: World Bank’s Doing Business
Source: Malaysia Productivity Corporation (MPC)
The government has formalised the mandate given to the MPC with the launching of
a national regulatory policy through the policy document “National Policy on the
Development and Implementation of Regulations (NPDIR)” in July 2013. The
document has been developed to support the modernization of the regulatory regime.
The document states:
Global competition, social, economic and technological changes require the government to consider the inter-related impacts of regulatory
regimes, to ensure that their regulatory structures and processes continue to be relevant and robust, transparent, accountable and forward-looking.
Essentially, the report is targeted to promote the NEM policy objective of improving
economic efficiency through enabling fair competition. The objective of the national
policy is to ensure that Malaysia’s regulatory regime effectively supports the country’s
aspirations to be a high-income and progressive nation whose economy is
competitive, subscribes to sustainable development and inclusive growth. The policy
is to ensure a regulatory process that is effective, efficient and accountable as well as
to achieve greater coherence among policy objectives of government.
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1.3 The approach and rationale of this review
Becoming a high-income nation requires, among other critical factors, an efficient
labour market that is able to attract, develop and retain the best talent and which does
not impede job mobility. Shortages of the required types of skills and talent will hamper
the transformation to a knowledge and innovation-based high income economy.
Efforts to reform the labour market are necessary to ensure efficient matching of
demand with supply, and to improve the retention of top talent and to enhance the
attractiveness of Malaysia to local and foreign talent as well as the Malaysian
diaspora.
During the period of the 10th Malaysia Plan, the Government had committed to
modernising the labour market, with special emphasis on improving job mobility and
upskilling the workforce, in particular those from the bottom 40% low-income earners.
The focus of the reform is on three key areas:
making the market more flexible
upgrading the skills and capabilities of Malaysia’s existing workforce
enhancing the Malaysia’s ability to attract and retain top talent.
The particular aspects which has been addressed in this review are those regulations
which impede mobility and flexibility and in other ways impose unnecessary regulatory
burdens on business. This is complementary to the 11th Malaysia Plan which calls for
the acceleration of such reforms through comprehensive and integrated governance
reforms including modernising the current regulatory regime to ensure a thriving and
competitive environment for the services sector. 3
1.4 Conduct of the study
The investigations have involved collection, review and analysis of data and information
from two sources: secondary data from literature reviews and primary data from
interviews with key stakeholders
3 11th Malaysia Plan on page 8-17
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Secondary data are from many sources and are classified as follows:
i. The Laws of Malaysia, particularly:
a. Private Healthcare Facilities and Services Act 1998 (Act 586)
b. Private Healthcare Facilities and Services (Private Hospitals and Other
Private Healthcare Facilities)Regulations 2006
c. Private Healthcare Facilities and Services (Private Medical Clinics or
Private Dental Clinics) Regulations 2006
d. Medical Act 1971 (Act 50) amendment 2012
e. Dental Act 1971 (Act 51)
f. Registration of Pharmacists Act 1951 (Act 371)
g. Nurses Act 1950 (Act 14)
h. Personal Data Protection Act 2010 (Act 709)
i. Personal Data Protection (Class of Users) Order 2013
j. Personal Data Protection (Fees) Regulations 2013
k. Personal Data Protection (Registration of Data User ) Regulation 2013
l. Personal Data Protection Regulations 2013
ii. Research papers published by international agencies such as the World Bank
and the World Health Organisation (WHO) and other countries such as the
AGPC, and the OECD
iii. Local research papers and reports commissioned by the government such as
the Economic Planning Unit (EPU) commissioned reports and Ministry of
International Trade and Industry (MITI) commissioned reports
iv. The Malaysian Government Plans such as the 5-year plans the Industrial
Master Plan 3 and the Knowledge Economy Master Plan.
v. Statistical data relating to medical professionals from both international and
local sources primarily the World Bank, Ministry of Health publications and
Department of Statistics Malaysia publications
vi. Other information derived from federal, state and local government agencies,
quasi-government bodies, professional bodies, private businesses and
relevant associations on policy matters, news, reports and statistics. Much of
this information has been accessed from websites.
7
Figure 1.2: Summary of the process of this research.
In order to identify the problems and issues that need to be addressed, primary data
was collected through interviews with business players, associations, professional
bodies and relevant regulators. The draft report is being released to enable
stakeholders including the main parties affected by the proposal i.e. the businesses,
non-governmental organisations (NGOs), the community, regulators and other
Government agencies to comment on the findings and options presented in the report.
Conceptualize Value Chain
List all Acts and map them
onto the Value Chain
Scoping & Targets
Identification
Develop a list of questions
Conduct interviews
Analyse Information
gathered
Draft report (with proposed
options)
Public consultations (other
feedback)
Final Report
LIT
ER
AT
UR
E R
EV
IEW
IN
PU
TS
(B
oo
ks;
Art
icle
s &
Sta
tisti
cs)
EX
PE
RT
’S A
DV
ICE
Ex-A
GP
C
8
The study is being carried out in two stages: the exploratory stage to prepare the draft
report and the option stage to produce a final report which will identify the most
appropriate options for reducing identified unnecessary regulatory burdens. With the
assistance of the AGPC expert, a list of questions was prepared for the interviews with
the respondents. The list of the interview questions is included in Appendix A of the
report.
After receiving comments on the draft report, the MPC will produce a final report
containing the MPC’s assessment and comments of final recommendations. Figure 1-
2 illustrate the process of this research.
1.5 Other initiatives by the Government
1) National Policy on the Development and Implementation of Regulation
This policy document applies to all federal government ministries, departments,
statutory bodies and regulatory commissions. It is also applicable for voluntary
adoption by state government and local authorities. The policy document spells out
the objectives, operating principles, responsibilities, requirements and process for the
regulatory process management.
The national policy also specifically mandates the MPC, through its responsibility to
the National Development Planning Committee (NDPC), to implement the functions
of the national policy. MPC is to assist in the coordination for implementing this policy4.
2) Best Practice Regulation Handbook
The Best Practice Regulation Handbook provides the detail guidance on carry out best
practice regulation – the systematic process to the development of regulations.
Basically, a regulator has to carry out regulatory impact analysis (RIA) and produced
a comprehensive report, the Regulatory Impact Statement when it is introducing any
regulation that may impact upon businesses. MPC role here is to ensure that the RIS
is adequately prepared before it is submitted to NPDC for further action5.
4 Government of Malaysia, Best Practice Regulation Handbook, July 2013 5 Australian Productivity Commission, Performance Benchmarking of Australian Business Regulation:
Cost of Business Registration, Research Report, November 2008
9
3) Guideline on Public Consultation Procedures6
The Guideline on Public Consultation Procedure was launched in October 2014. The
guideline which supplements the Best Practice Regulation Handbook aims to facilitate
the implementation of the National Policy for the Development and Implementation of
Regulations. It provides overview information, guiding principles, key requirements
and case study examples for planning and implementing public consultation
exercises.
1.6 Structure of the Report
This report on the Reducing of Unnecessary Regulatory Burdens (RURB) affecting
the medical professionals has been organised into seven chapters, starting with this
introductory Chapter One. This chapter highlights the rationale of this study and the
approach of the study.
Chapter Two refers to the overview of the Medical Professional Value Chain in
Malaysia and the policy implemented throughout the years. It covers the pertinent
statistics on the performance of healthcare sector and medical professionals in
Malaysia from 1990 to 2012.
Chapter Three looks at the regulatory burdens and the potential sources of
unnecessary regulatory burdens. The chapter concludes with the main
complaints/issues raised by the stakeholders.
Chapter Four provides an overview of the regulatory regimes for medical
professionals in Malaysia. It covers the value chain and all the related regulations
which are attached to each stage of the medical professional value-chain. It also
provides a brief description of the three main medical professional regulations in
Malaysia as well as employment policy in Malaysia.
Chapters Five, Six, Seven, and Eight present the analysis and findings of the
regulatory related issues for this study. Options are proposed for the regulatory issues
6 Government of Malaysia, Guideline on Public Consultation Procedures, October 2014
10
of concern. Although the study has identified a wide list of complaints/issues, the focus
is only to elaborate on pertinent regulatory issues that could be improved to create a
more conducive working environment, particularly for the private medical
professionals, who are the subject of the study.
11
Figure 1.3: Summary of the Regulatory Issues discussed in this study
1. Inadequate quality control of private
colleges providing health sciences
education
2. Supplies of clinical training for
housemen and nursing graduates
2. Lack of Regulatory Framework for
MCO Operation
- Minimal fees paid to medical
professionals
- Intervention on clinics operation
- Delayed and partial
reimbursement
- Selective Empanelling and Fee
Splitting
3. Discrepancies between Personal
Data Protection Act 2010 and
PHFSA 1998
- The Redundancy on Confidentiality
- Difficulties to gain access of data of Information
Pre-Qualification
Exit / Termination
Specialisation
General Practices
(GP)
12
Chapter 2: Overview of the Medical Professionals in Malaysia
2.0 Brief Overview of the Medical Professionals in Malaysia
This chapter provides an overview of the healthcare system in Malaysia as well as
the medical professionals serving the general public. It also illustrates the
importance of healthcare professionals and their development plan as stated in the
8th to 11th Malaysia Plan. In addition, the chapter also provides relevant statistics of
the healthcare sector.
2.1 History and Development of Healthcare System/Medical Professionals in
Malaysia
Malaysia inherited a health system from the British upon independence in 1957 but
with services based mainly in urban areas. Malaysian healthcare system had
evolved from a simple single provider system to one of multiple providers which are
categorised by public and private sector providers interacting with one another, as
well as, third party financiers. Each party interacts with each other in the process to
maximise their benefits. The government has provided the major healthcare and
healthcare related facilities where all are financed through central taxation. This
situation started to change during the 1980s due to growing demand for healthcare
following rising incomes, urbanisation and the expansion in the middle classes
(Chee & Barraclough, 2007).
Public dental services prior to independence were run by British dentists in the large
hospitals assisted by locally qualified dentists who also visited districts and towns.
Further, the private dental care was provided by about 450 mainly locally trained
practitioners.
Pharmacy services in Malaysia came into existence in 1951. In 1955, the numbers
of pharmacist was around 301. To enhance its role The Government Pharmaceutical
Laboratories and Stores were established in 1964 in Petaling Jaya to purchase and
manufacture pharmaceuticals for MOH services. However, the absence of
1 Malaysian Pharmaceutical Society (2016) History of MPS, available at : http://www.mps.org.my/index.cfm?&menuid=84
13
dispensing right has limited the community pharmacist’s professional roles to deliver
pharmaceutical care, optimize their clinical knowledge and utilize their skills2.
Nursing practice in the pre-war period in Malaya then was carried out by nurses who
received “on the job training”. After Independence, health services became mainly a
central government responsibility with delegation of service delivery through state
and district health administrations3. The first private nursing school in Malaysia was
established at Assunta Hospital, Petaling Jaya.
Figure 2.1: Schematic Overview of the Health System
Source: Hussein RH, Asia Pacific Region Country Health Financing Profiles: Malaysia, Institute for Health Systems Research
A schematic overview of the health system is shown in Figure 2-1. The MOH offers
a comprehensive range of services, including health promotion, disease prevention,
curative and rehabilitative care delivered through clinics and hospitals, while special
institutions provide long-term care. In addition, several other government ministries
2 Mohd A.Hassali, Vivienne M. S. Li, Ooi G. See (2014), Pharmacy Practice in Malaysia, Journal of Pharmacy
Practice and Research. 3 2013, Western Pacific Region Nursing and Midwifery Databank, available at : http://www.wpro.who.int/hrh/about/nursing_midwifery/db_malaysia2013.pdf
14
provide health-related services. The private health sector provides health services,
mainly in urban areas, through physician clinics and private hospitals with a focus
on curative care. Private companies run diagnostic laboratories and some
ambulance services. Non-government organizations provide some health services
for particular groups. Traditional medicine, such as Chinese and Malay practitioners
and products, is used by large sections of the population.
2.1.1 Malaysia Plan
In the mid 1980’s, the Malaysian government initiated a program on economic
liberalisation and deregulation that included a comprehensive privatisation policy, in
connection with the concept of “Malaysia Incorporated”. This concept sees the
Government as the provider of an enabling environment - infrastructure,
deregulation, liberalisation and macroeconomic management; and the private sector
as the main engine of growth (Economic Planning Unit, 1985, 1991). Gomez and
Jomo (1999) and Chee (2006) argue that the government was influenced strongly
by advisors from the Thatcher government of United Kingdom and the World Bank
to introduce privatisation as the vehicle to reduce government expenditure.
The Mid-Term Review of the Sixth Malaysian Plan 1991-1995 stated that: While the
government will still remain a provider of basic health services, the role of the
Ministry of Health will gradually shifts towards more policymaking and regulatory
aspects, as well as, setting standards to ensure quality, affordability and
appropriateness of care. At the same time the Ministry of Health will ensure an
equitable distribution in the provision of health services and health manpower
between the public and private sectors. (Malaysia Plan 1993:244)
Hence, in the following Seventh Malaysian Plan (1996-2000) it was stated that the
Government “will gradually reduce its role in the provision of health services and
increase its regulatory and enforcement functions” (Malaysia 1996:544). Following
strong promotion by the government towards the private healthcare particularly since
the mid-1980s has resulted in the steady rise of private hospitals. A number of large
Malaysian corporations and companies were set up by medical specialists, including
through the involvement of foreign investors who invested in private hospitals. Most
15
of the services in the private hospitals are paid from out-of-pocket bills. In addition,
the government also launched Government Linked Companies (GLCs) that, inter
alia, acquired shares or started large private hospitals4.
The Government has introduced and implemented various policies and objectives in
successive Malaysian Plans. Table 2.1 describes the conditions before the
implementation of each Plan and the policies undertaken by the Government to
develop human capital in Malaysia during the period of each Plan.
2.1.2 The Plan and Healthcare Professionals Development Policy-Thrusts
Table 2.1: The Health Professionals Development Policies from various Malaysian Plan
The Plan Health Professionals’ Development Policies
8th
Malaysian
Plan
(2001-2005)
- Expansion of public sector training institutions and the
outsourcing of training. In addition, Universiti Putra Malaysia,
Universiti Malaysia Sarawak and Universiti Islam Antarabangsa
will expand their medical faculties and teaching hospital facilities.
The Universiti Sains Malaysia will also establish a faculty of
dentistry in Kubang Kerian, Kelantan. The public and private
medical schools are expected to produce 5,374 graduates in
medicine, 708 in dentistry and 1,855 in pharmacy, during the Plan
period. About 200 students a year will continue to be sent
overseas to complement training by local institutions.
- A total of five new institutions to train allied health professionals
will be established in Alor Setar, Kedah, Johor Bahru, Johor, Kota
Kinabalu, Sabah, Kuching, Sarawak and Sungai Buloh, Selangor.
Inservice training for the allied health professionals will be
enhanced at the primary, secondary and tertiary care levels as
well as in the teaching hospitals, during the Plan period. Private
sector hospitals will also be encouraged to set up their own
training facilities as well as expand existing ones to meet their
manpower requirements. Greater emphasis will be given to the
post-basic training of allied health professionals in areas such as
anaesthesiology, paediatrics, oncology and radiotherapy.
4 University of Malaya, Student’s Repository, Healthcare in Malaysia
16
The Plan Health Professionals’ Development Policies
- Efforts will be undertaken to encourage all categories of health
manpower to remain in the public sector. In this regard, the
Government will further increase the supply of health manpower
as well as continue to review and improve the terms and
conditions of service for health and allied health professionals. In
addition, a more conducive working environment will be provided
by improving and upgrading the facilities in the hospitals and
clinics. In addition, greater opportunities will be provided for skills
upgrading and postgraduate training, particularly in areas such as
cardiothoracic surgery, rehabilitative medicine and neurosurgery.
9th
Malaysian
Plan
(2006-2010)
- An allocation of RM1 billion will be provided. A blueprint will be
formulated to improve human resource development as well as
address issues relating to the acquisition, training, supply,
utilisation and deployment of health personnel.
- Collaboration mechanisms will be instituted with relevant
government agencies and the private sector to increase training
capacities. In this regard, selected public hospitals will also be
utilised as teaching hospitals. In addition, students will be sent
overseas to complement training undertaken by local institutions.
- The continuous professional development (CPD) programme will
be further strengthened through the provision of online facilities to
develop the skills and competencies of medical personnel. CPD
activities will be monitored to ensure enhanced quality,
professionalism and will be matched with the required
competency tests. In addition, efforts will be undertaken to
enhance the knowledge and competencies of medical personnel
in new areas of specialisation and subspecialties such as vaccine
development and health-related disaster management, through
in-service training. Priority will also be given to ensuring sufficient
supply of trained personnel to address the behavioural
component of lifestyle issues.
17
The Plan Health Professionals’ Development Policies
- The completion of seven training colleges for AHSP during the
Plan period will enable an additional 25,000 personnel to be
trained. To further improve and upgrade the skills and knowledge
of trained personnel, post basic training in new and priority
disciplines will be conducted. In addition, the development of soft
skills, including the inculcation of good ethics, values as well as a
caring attitude will be given greater emphasis. Measures will also
be undertaken to increase the number of tutors as well as upgrade
their skills.
10th
Malaysian
Plan (2011-
present)
Investments in human resources for health (HRH) remain a central
component of the healthcare system.
- The doctor-population ratio is expected to improve from 1:1,380
in 2005 to 1:597 in 2015, while the nurse-population ratio is also
expected to increase from 1:592 to 1:200 during the same period.
In order to cope with the increased demand for training, the
Government will increasingly utilise specialists from the private
sector for training, as 60% of total specialists available in the
country are in the private sector.
- In addition, the Government will continue to outsource and
collaborate with private training institutions for the training of allied
health personnel. Other efforts to meet the rising demand for
quality healthcare will focus on the following efforts:
• Increasing the specialist training allocation for doctors and
other healthcare professionals;
• Improving and expanding post-basic training for nurses and
allied healthcare personnel;
• Addressing personnel retention through provision of better
remuneration, promotional opportunities and steps to provide
greater job satisfaction; and
• Improving the quality of private healthcare professionals
through credentialing, privileging and structured training.
18
The Plan Health Professionals’ Development Policies
11th
Malaysian
Plan (2016-
2020)
Under Chapter 4, wellbeing remains a priority thrust for realising Vision
2020. The Government will accelerate efforts to achieve universal
access to quality healthcare by targeting underserved areas, and
increasing capacity of both facilities and healthcare personnel.
- Under focus area A, Achieving Universal Access to Quali ty
Healthcare, Governments remain committed to achieving
universal access to quality healthcare by continuing efforts to
improve the fundamentals of the health systems. Under this
focus area, the highlighted strategies are as follows:
Strategy A1 : Inclusiveness- Enhancing targeted support,
particularly for underserved communities. The extension of
services to poor and low-income households, Orang Asli in
Peninsular Malaysia, and rural and remote areas in Sabah
and Sarawak will include the deployment of more specialist
and skilled personnel.
Strategy A2 : Improving System Delivery for Better Health
Outcomes. The Government will implement the hospital
cluster concept in selected locations, where hospitals within
the same geographical location will work as one unit, sharing
resources such as assets, amenities and human resource.
Strategy A3 : Expanding Capacity to Increase Accessibility.
The private sector will be encouraged to collaborate and set
up more healthcare facilities that cater to the needs of low
and middle income household.
Strategy A4 : Intensifying Collaboration with Private Sector
and NGO to Increase Health Awareness. Such collaboration
will span a broad range of initiatives, from community health
and prevention programmes, to research and development
efforts between industries, universities and research
institutions.
- Doctor to population ratio is expected to improve to1:400 in the
11th Malaysia Plan instead of 1: 597 in 10th Malaysia Plan.
19
The Plan Health Professionals’ Development Policies
- 2.3 hospitals beds per 1000 population that includes public and
private hospitals, maternity and nursing homes, hospices and
ambulatory care centres.
2.2 The Population, life expectancy and mortality rates of Malaysian
Malaysia is classified by the World Bank as an upper middle-income country. In
2014, with the total land area is 330, 289 sq. km5 the total population in the country
is 30.3 million6. Although, the annual population growth rate over the years have
declined to around 1.6% in 2013 (refer to table 2-1), the growth rate is similar with
other neighbouring countries like Singapore (1.6%), Brunei Darussalam (1.3%),
Philippines (1.7%) and Indonesia (1.2%). Malaysia is undergoing a demographic
transition as the total fertility rate7 has fallen to 2.1 births per woman, the population
proportion below age of 15 has fallen to 26% and those aged 65 years and above
are increasing. This is consistent with the increase in life expectancy at birth over
the years.
Table 2.2: Population distribution and Vital Statistics
Indicator1 2000 2005 2010 2011 2012p 2013e 20142
Total population (millions) 23.5 26.0 28.5 29.1 29.5 29.9 30.4
Population aged 0-14 (% of
total) 33.1 32.6 27.4 26.9 26.4 26.0 25.6
Population aged 15-64 (% of
total) 62.9 63 67.6 68.0 68.3 68.5 68.7
Population aged 65 years and
above (% of total) 4.0 4.3 5.0 5.1 5.3 5.5 5.7
Average annual population
growth rate (%) 2.4 2.1 1.8 1.3 1.3 1.3
Crude birth rate (per 1000
population) 24.5 19.6 17.2 17.6 17.2 17.2 16.9
5 Department of Survey and Mapping, Malaysia 6 Department of Statistics, Malaysia 7 Total Fertility Rate refers to the average number of children which would be born if women survived to the end of their reproductive period and throughout that period are subject to the schedule of age-specific fertility rates for the given year.
20
Crude death rate (per 1000
population) 4.4 4.4 4.6 4.7 4.6 4.7 4.7
Total fertility rate 3.0 2.4 2.1
Life expectancy at birth
- Male - Female
70.2
75.0
70.6
76.4
74.08
74.32 74.54 74.72
72.5
77.2
p: preliminary data
e: estimated data
1: Data derived from Ministry of Health
2: Data derived from Department of Statistics
The 10th Malaysia Plan indicated that Malaysia has done well in extending affordable
basic healthcare services to all citizens. Malaysia healthcare system was also
highlighted as one that has been relatively successful in providing equitable
healthcare in terms of targeting public health subsidies towards the poor.
The World Bank statistics in 2012 (Chart 2-1) shows that in Malaysia, the total health
expenditure per capita was US$409.5 per person as compared to countries like
Singapore at US$2,426.1 per person and the United States at US$8,895.1.
21
Figure 2.2 : Health Expenditure per Capita (current US$)
Source: The World Bank, 2015
In relation to above, the total expenditure on health in ringgit Malaysia shows a
gradual increase over the years. In 2011, the expenditure from both public and
private healthcare are amounted to RM37,871 million as compared to RM35,148
million in 2008. The Malaysia’s public health system is financed mainly through
general revenue and taxation collected by the federal government, while private
sector is funded through private health insurance and out-of-pocket payments from
consumers (WHO, 2013)8. The health expenditure has remained predominantly
public spending, representing 52.3% and 54.7% of total health expenditure in 2011
and 2010 respectively.
Managed Care Organisation (MCO) has existed since 1995. They form as third party
payers within the healthcare industry. These MCO will be discussed in Chapter 7.
8 World Health Organisation (WHO) on behalf of Asia Pacific Observatory on Health Systems and Policies (2013) Malaysia Health System Review
2005 2006 2007 2008 2009 2010 2011 2012
Malaysia 179.2 221.7 255.5 288.2 285.2 345.1 384.2 409.5
Singapore 1058.2 1166.9 1333.1 1576.8 1703.7 1893 2144.3 2426.1
Indonesia 35.5 46.5 58 61.1 64.2 86 99.4 107.7
Thailand 95.5 109.8 133.2 161.6 163.6 182.9 213.9 215.1
Philippines 47 55.3 65.4 73.8 78.1 90.3 104.7 118.8
0
500
1000
1500
2000
2500
3000
Health Expenditure per capita (current US$)
Malaysia Singapore Indonesia Thailand Philippines
22
2.3 Health Human Resources
Human capital and health improvement programmes are of central importance
towards sustainable development and economic growth in any country. The
distribution of doctors or other healthcare resources are mostly at the public hospitals
rather than in the private sectors. Throughout the years, registered nurses are the
largest group of medical professionals. The statistics by the Ministry of Health in
2013 shown that almost 50% of medical professionals in Malaysia are represented
by nurses (including the community and dental nurses), totalling of 116, 379 nurses.
Table 2.3: Health professionals in the public and private sector, 2013
Health professionals Public Private Total Profession:
population ratio
Doctorsa 35,219 11,697 46,916 1:633
Dentists 3,256 1,979 5,235 1:5,676
Pharmacists 6,752 3,325 10,077 1:2,949
Opticians - 3,060 3,060 1: 9,711
Optometrists 308 1,015 1,323 1: 22,460
Asst. Medical Officers 11,089 1,428 12,517 1: 2,374
Nurses 62,514 26,653 89,167 1: 333
Pharmacy Assistant 4,294 552 4,846 -
Asst. Environmental Health Officers 4,287 n.a 4,287 -
Medical Lab. Technologists 6,108 n.a 6,108 -
Occupational Therapists 858 n.a 858 -
Physiotherapists 1,178 n.a 1,178 -
Radiographers (Diagnostic & Therapist) 2,699 n.a 2,699 -
Dental Nursesb 2,793 - 2,793 -
Community Nursesc 24,152 267 24,419 -
Dental Technologists 1,000 765 1,765 -
Dental Surgery Assistants 3,903 39 3,942 -
23
Traditional & Complementary Medical
Practitionersd - - 12,532
Source: Ministry of Health, 2014
a: Includes House Officers
b: Equivalent to Dental Therapists, provide public sector services for population under 18 years
of age
c: Includes Midwives
d: refers to registration of local and foreign practitioners
While the ratio of profession to population shows that the gap is being reduced
throughout the years many studies cited that Malaysian health system is being
seriously constrained by shortages of health professionals9. The Country Health
Plan: 10th Malaysia Plan stated that adequate workforce with the right mix of
numbers and skills remain elusive.
Table 2.4 : The ratio of health professionals to population, 2008 - 2013
Profession
Profession: Population Ratio
20081 20102 20123 20134
Doctors 1:1,105 1:859 1:758 1: 633
Dentists 1:7,618 1:7,437 1:6,436 1: 5,676
Pharmacists 1:4,335 1:3,652 1:3,039 1: 2,949
Asst. Medical Officers 1: 3,054 1:2,738 1:2,477 1: 2,374
Nurses 1:512 1:410 1:345 1: 333
Sources:
1: Health Facts 2008, Ministry of Health Malaysia
2: Health Facts 2010, Ministry of Health Malaysia
3: Health Facts 2013, Ministry of Health Malaysia
4: Health Facts 2014, Ministry of Health Malaysia
9 World Health Organisation (WHO) on behalf of Asia Pacific Observatory on Health Systems and Policies (2013) Malaysia Health System Review
24
The country is also aligning its effort to meet the WHO 1:600 ratio between doctors
to population in addition to establishing the country as the preferred destination of
health tourism in Asia. Health Tourism contributed RM688 million revenue in 2013
and is expected to double by 2020. The services sector, in particular medical
professional services, plays an important role in supporting the growth. The Annual
Global Retirement Index for 2014 which voted Malaysia among the top five best
places to retire, also poses a potential increase in the demand for medical
professionals which spawns employment opportunities for these professionals,
(source: International Living, NST online 11/01/2015)
Table 2-3 indicates that the most favorable ratio appears in the number of nurses to
population which is 1: 333. The ratio between doctors to population has improved
significantly from 1: 1105 in 2008 to 1: 633 in 2013.
The number of medical professionals in the country is also growing with 5,000
medical graduates entering the medical workforce each year. In addition to that,
Malaysia also gets 1,000 specialised medical experts a year, being part of the
nation’s aim to provide 1 doctor for every 400 population. There are around 221,000
health professionals in Malaysia as shown in Table 2-2 above, not including the
Traditional & Complementary Medical Practitioners.
The number of private hospital is also expected to increase from 225 in 2012 to 239
in 201810. The private hospital services market in Malaysia earned revenues of
RM7.5 billion (US$2.3 billion) in 2011 and is expected to reach RM13.8 billion (US$
4.2) in 2015. The revenue for private hospitals has almost doubled in four years.
Approximately 10% of the private healthcare revenues are from medical tourists11.
In closing the gap between health professionals with the Malaysian, the Government
had established collaboration between the anchor institutions from education sector
and allied health industry (Economic Transformation Programme 2011– EPP 8:
Building a Health Sciences Education Discipline Cluster. During the first phase,
10 Frost & Sullivan (2013) Malaysian healthcare sector to reach US$3.65 billion in 2018, Malaysian Journal of Nursing Online News Portal, Available at: http://mjn-e-news.com.my/may2013/top1.html (Accessed on 24 February 2015) 11 Nadaraj, V., (2014) Malaysia’s Healthcare Tourism: The Path is Paved with Gold, The Establishment Post, Available at: http://www.establishmentpost.com/malaysias-healthcare-tourism-path-paved-gold/ (Accessed on 24 February 2015)
25
these anchor institutions were responsible for building partnerships with smaller
training colleges and developing a portfolio of joint programme offerings from
diplomas to postgraduate degrees, as well as setting up joint investment vehicles to
pool private investments to develop critical infrastructure like clinical labs and
teaching hospitals.
During the second phase, from 2012 to the end of 2013, the cluster was broadened
to include any institute that meets the quality standard, including international
educational institutions to health service providers. The Ministry of Health and
Ministry of Higher Education, MOHE had envisaged to support the growth of the
cluster through a number of incentives, for example facilitating the export of health
care professionals through government-to-government agreements, allowing the
increased use of human-patient simulators as a partial (20 per cent) substitute for
clinical postings and restructuring the approval process for student quotas so that
institutions with good track records can be approved for increases in student
numbers based on planned capital expenditure instead of finished infrastructure.
2.3.1 Healthcare Facilities
The healthcare facilities are heavily offered by the public sector and are distributed
throughout the country while the facilities offered by the private sector are highly
concentrated in the urban areas due to the demand by the affluent community12.
Figure below shows that in 2010, 68% of private hospitals (173 hospitals) are located
at Selangor, Kuala Lumpur, Pulau Pinang and Johor Bharu while, the highest
locations for public hospitals are at Sabah and Sarawak.
12 S. Thomas et al., (2011) Health care delivery in Malaysia: changes, challenges and champions; Journal of Public Health in Africa 2011; 2:e23
26
Figure 2.3 : The Distribution of Government Health Clinic in Malaysia 2013
Source: MOH
359
283
258
88
144
326333
39
96
290
230
194
175
30
114
0
50
100
150
200
250
300
350
400
JHR KDH KEL MLK NS PHG PRK PS PP SBH SRWK SEL TRG KL WPL WPP
Nu
mb
ers
of
Clin
ics
States
The Distribution of Government Clinic in 2013
27
Figure 2.4 : The Distribution of Private Health Clinic in Malaysia 2011
Source : KKLW
786
324
190
272 260225
607
30
477
329 316
1628
153
983
9
0
200
400
600
800
1000
1200
1400
1600
1800
JHR KDH KEL MLK NS PHG PRK PS PP SBH SRWK SEL TRG KL WPL
Nu
mb
ers
of
Ho
spit
als
States
The Distributions of Private Health Clinic in 2011
28
Figure 2.5 : The Distribution of Government Hospital (MOH) in Malaysia 2013
Source: MOH
11
9 9
3
6
10
14
1
6
22
21
11
6
1 1 1
0
5
10
15
20
25
JHR KDH KEL MLK NS PHG PRK PS PP SBH SRWK SEL TRG KL WPL WPP
Nu
mb
ers
of
Ho
spit
als
States
The Distribution of Government Hospital in 2013
29
Figure 2.6 : The Distribution of Private Hospital in Malaysia 2013
Source: MOH
27
9
34
9 9
16
0
23
5
12
56
1
40
0 0
0
10
20
30
40
50
60
JHR KDH KEL MLK NS PHG PRK PS PP SBH SRWK SEL TRG KL WPL WPP
Nu
mb
ers
of
Ho
spit
als
States
The Distribution of Private Hospital in 2013
30
Similarly, most primary health care is offered in urban areas, while the public primary
health care facilities are mainly located in rural areas. There are 6,442 private clinics
compared to 2,833 Ministry of Health clinics (Table 2-5), although private clinics are
mainly small practices with single practitioner or few with small group
arrangements13. This is similar with the private dental clinics. Reported by the WHO
in 2013, about 80% of the private dental clinics are single-practitioner practices and
about 45% of private dental clinics are in urbanized states of Selangor and the
Federal Territories of Kuala Lumpur and Putrajaya.
Figure 2.7 : The Distribution of Public and Private Hospital for each State Malaysia2013
Source: MOH
13 World Health Organisation (WHO) on behalf of Asia Pacific Observatory on Health Systems and Policies (2013) Malaysia Health System Review
13
9
9
9
6
10
16
1
7
23
22
13
6
4
1
1
3710
55
99
151
267
1765
345
00
0 20 40 60 80 100
JHR
KDH
KEL
MLK
NS
PHG
PRK
PS
PP
SBH
SRWK
SEL
TRG
KL
WPL
WPP
The Distribution of Public and Private Hospital for Each
State in 2013
The Number of
Public Hospital
The Number of
Private Hospital
31
Table 2.5 : Primary care health facilities, 2010
Primary care health facility 2010 2013
MoH Private MoH Private
Health clinics1 2,833 6,442 2,860 6,801
Health clinics (1 Malaysia) 53 - 254 -
Dental clinics2 1,744 1,512 1,629 1,686
Source: Health Facts 2010, Health Facts 2014, and Health Indicators 2010, Ministry of
Health
1: Health clinics include Community clinics (Klinik Desa) and Maternal & Child Health
clinics.
2: Dental clinics exclude mobile dental clinics
2.3.2 Trends in Health Workforce
The Country Health Plan: 10th Malaysia Plan emphasizes that for sustainable
services, the health professionals in the country need to have various range and
level of competencies with adequate numbers supplied. The latter is the most
challenging criteria for Primary Health Care (PHC) services to ensure equity and
accessibility to services. For secondary and tertiary services, the rise of new
technology and new type of care requires not only adequate numbers but need to
be competent with new technology and interventions. As care becomes more
complex and intensive, the probability of medical errors is higher and competency of
the workforce must be absolute.
The development of healthcare workforce in Malaysia is also attributable to the
sound deployment of technology by the medical professionals. These investments
include computer hardware and software. Online patients’ reporting systems
enable radiologists to transmit patients’ MRI or X-ray results to doctors anywhere in
the world, thus enabling more flexible medical professional services. Such facilities
provide higher competitive advantage to more established practitioners, especially
those operating in remote areas. Like other software, there are also compatibili ty
issues faced by Medical Professionals. Therefore, there often include additional
investment to upgrade existing systems and training on the usage of the new
technology, which could be burdensome to small private clinics and facilities.
Technology has also made drugs prescription easier. However, it could pose
32
danger to patients who could purchase freely from the internet and have the drugs
consumed without prescription from any doctors or certified medical professionals.
The country health system, particularly the public sector is experiencing shortages
of health professionals. In 200814, 60% of the doctors are in the public sector but
60% of the specialists are in the private healthcare services. Although the workload
per doctor in private hospitals is significantly less than in public facilities.
Figure 2.8 : Admissions and Outpatient Attendances, 2013
Source: MOH,2013
14 World Health Organisation (WHO) on behalf of Asia Pacific Observatory on Health Systems and Policies (2013) Malaysia Health System Review
33
Figure 2. 9 : Public and Private Sector Resources and Workload, 2008
Source: MOH, 201015
On top of difficult working conditions in public hospitals, salaries and benefits offered
by the private and international sectors are more attractive than the public sector,
thus the competition in the labour market clearly favours them. The Country Health
Plan further stated that there have been existing concerns on shortage of doctors in
the public health sector, and imbalanced distribution in remote areas, certain states,
some critical areas, and difficulty in placement and retention of doctors and nurses
in these areas.
Meanwhile, the growth of the private health care sector has triggered the migration
of senior doctors, specialists and experienced allied health professionals from the
public sector to the private sector. The attrition rate in MOH from 2005-2008 is shown
in Table 2.7 below. Stated by the MOH that some of the factors affecting the increase
in attrition rate are lucrative offers from the private and international sectors, the
opportunity to join institutions of higher learning as trainers or the opportunity to
operate their own clinics.
15 MOH (2010) Country Health Plan, 10th Malaysia Plan 2011-2015
34
Table 2.6 : Attrition among Doctors and Dentists in MOH
Category 2005 2006 2007 2008
Doctors 401 248 300 478
Dentists 56 78 107 77
Total 457 326 407 555
Source: Ministry of Health, 201016
The increase in attrition rate of senior doctors, specialists and experienced health
professionals raise the uncertainty of whether the house officers and other
professional’s health residents receive adequate clinical exposure during the
residency training. In order to achieve the status of a high income country, it is vital
for Malaysia to have an increase in the density of health workforce (see the
comparison of the density of health workforce in Malaysia with the high income
country and the global rate in Table 2-7). Despite the attempt to match the
global/high income country rate (by increasing the number of medical graduates),
number of training placement in the country remain statics. In 2013, Dr Milton Lum
(MMC member and senior medical practitioner) stated that less than 50 hospitals in
the country are equipped with the necessary training facilities17. The most apparent
impact would be the increase in probabilities of unemployment of medical graduates
Oversupply of nursing students are also one of the major concerns in healthcare
sector. In 2010, 54% of the private nursing diploma graduates faced difficulties in
finding job three to four months after graduating, compared to 21.7% in 2008 while
many of the degree graduates are working in the sector with salary of less than the
norm, i.e. being paid with the salary scale of diploma holders. While the production
of graduates in healthcare sector keeps on increasing, Malaysia is still lagging
behind of the goal for a high income country (refer to the table 2-7). This might be
due to the quality of graduates produced and insufficient training placement/work
place.
16 MOH (2010) Country Health Plan, 10th Malaysia Plan 2011-2015 17 Chin, C., (2013) Too many doctors, too little training, The Star, 18 August. Available at: http://www.thestar.com.my/News/Nation/2013/08/18/Too-many-doctors-too-little-t raining/ [Accessed on 26 March 2015]
35
Table 2.7 : Density of health workforce (per 10,000 population), 2014
Physicians
Nursing
and
Midwifery
personnel
Dentistry
personnel
Pharmaceutical
personnel
Malaysia 12.0 32.8 3.6 4.3
Upper Middle Income 15.5 25.3 … 3.1
High Income 29.4 86.9 5.8 8.4
Global 14.1 29.2 2.7 4.3
Source: WHO, 201418
Healthcare professionals are also exposed to dangerous working conditions.
Selangor Health Department director Dr S. Balachandran reported that they are
highly at risk at contracting dangerous diseases due to the nature of their work. The
recent report showed that 45 healthcare workers were infected with TB in 201419,
causing three deaths.
Healthcare professionals also face a high rate of burnout. This is due to the common
problems of inadequate staffing, high public expectations, long work hours, exposure
to infectious diseases and hazardous substances, threat of malpractice litigation and
the constant encounters with death and dying. Studies indicated that healthcare
workers have long been known to be a highly stressful group and were worryingly
associated with higher rates of psychological distress than many other workers of
different sectors.
A cross-sectional study was conducted among 376 medical & medical sciences
undergraduate in University Malaysia, 46% felt stress20. The most common stressor
was worried of future followed by financial difficulties. The Star Online reported that
one out of five doctors undergoing their houseman quits annually in Malaysia and
some are working as waiters, running pasar malam stalls and even an air
18 WHO (2014) World Health Report 19 The Sun (2015) Healthcare workers warned against TB, The Sun Daily, 8th May, p.12 20 The Malaysian Journal of Medical Sciences. Available at http://journal.usm.my/journal/mjms-full18-3.pdf
36
stewardess21. The resignation rate is alarming given that it costs up to RM500,000
to acquire a medical degree locally and up to RM1 million overseas. The portal
reported that many newly qualified doctors were also quitting because of the longer
wait to be posted as housemen. The issue will be elaborated in the Chapter 5.
Recent development has also shown that doctors operating private clinics have been
forced to closure due to capped price pressure. The fees of General Practitioners
(GPs) in private clinics as per Schedule 7th and 13th of the Private Healthcare
Facilities and Services Act 1998 are stated as follows:-
Table 2.8 : Seventh Schedule 2006 and Thirteenth Schedule 2013
Seventh Schedule 2006:
Part I-Medical Fees
A. Consultation Fees
1. General Practitioners (Non specialists)
(a) Clinic with pharmaceutical services
Consultation only
Consultation with examination
Consultation with examination and
treatment plan
Consultation after stipulated clinic hours
House calls or home visits
Revision has been made in 2013, and the new fees
schedule has been introduced:-
RM 10 - RM 35
Up to 50% above the
usual rate
Up to 100% above the usual rate
Thirteenth Schedule 2013
Consultation only
Consultation with examination
Consultation with examination and treatment plan
RM 30-125
Up to 50% above the
usual rate
Up to 100% above the
usual rate
21 The Star Online (March 30, 2015) in an article ‘Housemen do not complete training stint for various reasons’. Available at http://www.thestar.com.my/News/Nation/2015/03/30/One-in-five-quit-each-year-Housemen-do-not-complete-training-stint-for-various-reasons/
37
Consultation after stipulated clinic hours
House calls or home visits
Source: Schedule 7th and 13th of Private Healthcare Facilities and Services Act 1998 (Regulations 2006)
However MCO’s rate for panel clinics still does not reflect the change in the schedule
thirteenth as mentioned by some doctors that were interviewed. General panel
practitioners have been capped to a RM30 to RM35 claimable fees for both
consultation and medicine prescribed to patients registered under these MCOs.
Such trading practices may lead to the issues faced by private doctors as per the
situation mentioned above. More of this will be discussed in Chapter 6.
38
Chapter 3: Best Practice Regulations and Regulatory Burdens
3.0 Best Practice Regulations and Regulatory Burdens
This chapter discusses the concepts of regulation, the costs associated with
regulations and how to identify necessary and unnecessary regulatory burdens. It
complements the broad purpose of the review which is to identify unnecessary
regulatory burdens affecting businesses in Malaysia and suggest ways to reduce
them.
3.1 What is Regulation?
For the purpose of these references, regulation is defined broadly to include all
written legal and quasi-legal instruments ranging over primary legislation,
secondary instruments, guidelines, circulars, codes, standards and others. The
conditions contained in licences, permits, consents, registration requirements and
leases are also under review where they impose a compliance burden on
businesses.
As well as the content of written regulations, the way they are implemented,
administered and enforced can also significantly impact on compliance burdens for
businesses and the effectiveness of regulations. Hence, the delivery of regulation
is also under review.
The MPC is assessing both written regulation and the administration and
enforcement of the regulation. Hence, participants have been able to raise
concerns about any aspect of the regulatory framework.
3.2 Cost of Regulation
There are many different sorts of costs which may be imposed by regulation in
order to achieve policy objectives. The costs impact variously on businesses,
employees, consumers and governments. What is important is that the total
benefits accrued from achieving the regulatory objectives must be greater than the
39
total costs of the regulation. Regulations can adversely impact on businesses in
various ways. Most fall under the following four categories of costs:
administrative and operational requirements, such as:
reporting, record keeping
getting legal advice, training
requirements on the way goods are produced or services supplied, such as:
prescriptions on production methods
occupational registration requirements, requiring professionals to use
particular techniques
requirements on the characteristics of what is produced or supplied, such as:
being required to provide air bags in all motor vehicles
requiring teachers or trainers to cover particular topics
lost production and marketing opportunities due to prohibitions, such as:
when certain products or services are banned
The direct costs of complying with regulations can include the time taken to comply
with regulations, the need for additional staffing, the development and
implementation of new information technology and reporting systems, paying for
external advice, education, advertising, and accommodation and travel costs.
Compliance costs also impact indirectly on the community, by changing pricing and
distorting resource allocation, impacting on international trade and delaying the
introduction of new products or services.
In an international study in 1998, the OECD estimated from survey responses that
taxation, employment and environmental regulation imposed over $17 billion (2.9
per cent of GDP) in direct regulatory compliance costs on small and medium-sized
businesses in Australia.
The more advanced countries like Australia have taken measures to improve the
cost-effectiveness of regulations and to reduce compliance burdens and red-tape.
These measures include:
increased adoption of performance-based regulation
he consideration and adoption of implementation options that minimize red-tape
the improvement of regulatory services through the employment of new
technology
40
increased electronic publication of regulatory information
licence reform and reduction
streamlining government paperwork requirements
privatization of certification functions
business focus groups and pilot test programs
3.3 What are Unnecessary Regulatory Burdens?
Some regulatory costs are inevitable in order to achieve the benefits which the
regulation brings. High quality regulation is both effective in addressing an
identifiable problem or objective and efficient in terms of minimizing unnecessary
compliance and other costs imposed on business and the community. The best
regulations achieve their objectives and at the same time deliver the greatest net
benefit to the community. By contrast, poor quality regulation may not achieve its
objectives and can impose unnecessary costs, impede innovation, or create
unnecessary barriers to trade, investment and economic efficiency. Given the
pervasiveness of regulations, it is not surprising that regulation and red-tape
continue to impose significant compliance costs (Argy and Johnson, 2003)1.
There are sound reasons for much regulation. It can reflect and enforce the
community’s values and rights of individuals. It can reduce risks to people’s health
and safety (such as through consumer policy), address discrimination (such as an
equal opportunity laws), and protect the environment from overuse or degradation.
Regulation is also part of the institutional architecture for markets to work
efficiently, including by establishing property rights and enforcing contracts.
Much regulation is aimed at addressing market failures — asymmetric information,
monopoly power; externalities and public goods. Market failures can reduce
productivity, result in over- or under-production of particular products, services or
side-effects (such as pollution) relative to community preferences, and distort
consumption and production decisions. Regulation can also reduce social and
environmental risks. However, regulation to correct these market failures or to
1 Argy, Steven and Johnson, Matthew (2003) Mechanisms for Improving Quality of Regulations: Australia in an International Context, Staff Research Paper, Australia Government Productivity Commission
41
address risks, still needs to be efficient and effective, and the benefits of such
corrections need to outweigh the costs of implementing and complying with the
regulation. In addressing market failures, policy makers should be wary of creating
government failures.
Regulation can also be used to protect some producers at a cost to others, favour
the use of some resources relative to others, and/or benefit some consumers over
others. In some cases such changes are intentional and desirable – for example,
to look after vulnerable consumers and the environment to encourage longer-term
sustainability. However, in other cases, there may be no merit in this - the costs
imposed can be considerable and not justified by the benefits.
3.4 Sources of Unnecessary Regulatory Burden
Regulatory burdens are often necessary for government to achieve national policy
objectives. However, when regulations are poorly written or enforced or inefficiently
implemented, regulatory burdens will exceed what is necessary to achieve desired
objectives, giving rise to “unnecessary regulatory burdens”2
Unnecessary burdens might arise from:
1. excessive coverage by a regulation – where the regulation affects more
economic activity than was intended or needed to achieve its objective
(includes ‘regulatory creep’)
2. subject-specific regulation that covers much the same issues as other
generic regulation
3. prescriptive regulation that unduly limits flexibility such as preventing
businesses from:
using the best technology
making product changes to meet consumer demand meeting the underlying objectives of regulation in different ways
4. overly complex regulation
5. unwieldy licence application and approval processes, excessive time delays
in obtaining responses and decisions from regulators
6. requests to provide more information than needed
7. requests to provide the same information more than once
8. rules or enforcement approaches that inadvertently result in business
operating in less efficient ways
2 Malaysia Productivity Corporation (2014), Handbook on Reducing Unnecessary Regulatory Burdens: Core Concept, Available at: http://www.mpc.gov.my/ [Accessed on 30 March 2014]
42
9. unnecessarily invasive regulator behavior, such as overly frequent
inspections
10. an overlap or conflict in the activities of different regulators
11. inconsistent application or interpretation of regulation by regulators
The MPC has sought insights from businesses and other interested parties
about how the regulation of employment imposes unnecessary burdens on
business.
3.5 Best Practice Regulation
The MPC has published a set of principles that may help to assess the quality of
regulations and identify the unnecessary burdens on business as listed in box 3.1.
Box 3.1 : Six Core Principles for Assessing Regulation and its Administration
Regulations that conform to best practice design standards are characterized by the following six principles and features. Principle 1
Have a proportionate and targeted response to the risk being addressed. Principle 2
Minimize adverse side-effects to only those necessary to achieve regulatory objectives at least cost.
Principle 3
Have a responsive approach to incentivize compliance with regulation. Principle 4
Ensure all written regulations are consistent and that regulations are consistent and that regulators interpret and apply them consistently. Avoid duplication and overlap of regulations and regulators.
Principle 5
Adopt transparency criteria, so interested parties are regularly consulted, it is clear to businesses what their legal obligations are, and all regulations are easily accessed by everyone.
Principle 6
Accountability so that businesses can seek explanations of decisions made by regulators, as well as appeal them and there are probity provisions in order to reduce corruption.
Source: MPC (2014)
These principles guided the MPC’s identification of various key indicators of well -
written regulations (Box 3-2).
43
Box 3.2 : Well-Written Regulations
According to the MPC, well-written regulations are unlikely to impose unnecessary burdens on business. Indicators of these include:
i. the requirements placed on business are proportionate to the risk being regulated, in particular low risks are not addressed by imposing onerous requirements
ii. the regulations make appropriate use of prescriptive, performance, in-principle and process-based requirements
iii. the regulatory requirements are the minimum necessary to effectively achieve the objective(s) of the regulation
iv. in line with responsive regulation, the regulations provide an adequate range of enforcement instruments to allow regulators some flexibility in addressing non-compliance
v. the regulations are consistent with other regulations and do not create conflict or duplication
vi. the regulations are transparent, communicated effectively and readily accessible by everyone
vii. the regulation place accountability requirements on the regulator such as reporting, appeal and review provisions including some that address probity.
Source: MPC 20143
Regulations that have been formulated through Regulatory Impact Assessment
(RIA) are likely to reflect the indicators listed above. However, not many of the
current regulations have undergone the RIA process. This makes it important to
have ex-post regulatory reviews of unnecessary burdens on businesses to assess
the practicality of the regulations, help to improve them and most importantly
reduce the burdens on business3.
A regulator plays an important role in regulatory regimes by encouraging
compliance through education and advice, as well as enforcing laws and
regulations through disciplinary means3. Enforcing regulations, however, with
established principles of good practices can enhance regulatory practices to
achieve policy objectives. The box below indicates the indicators of good quality
implementation of regulation. These indicators also reflect the Principles for
Assessing Regulation and its Administration (Box 3-1).
3 Ian Bickerdyke, Ralph Lattimore, Reducing Regulatory Burden: Does Firm Size matters?, Industry Commission Australia, Staff Research Paper, December 1997
44
Box 3.3 : Key Indicators of Good Performance by Regulators
Based on Parker (2000), the MPC (2014) listed 10 indicators that describe a well
performing regulator:-
i. uses risk analysis to identify areas of intrinsically potentially high adverse
impacts and/or possible low compliance (in line with principle 1)
ii. maximizes the potential for voluntary compliance (in line with principles 2 and 3)
iii. uses a range of enforcement instruments flexibly in order to respond to different
types of non-compliance – responsive regulation (in line with principle 3)
iv. applies regulations consistently across businesses and industry sectors (in line
with principle 4)
v. has no duplication and overlap of its responsibilities with those of other
regulators (in line with principle 4)
vi. has sufficient transparency to enable business to know the requirements of the
law (in line with principle 5)
vii. maintains an ongoing dialogue between government and the business
community (in line with principle 5)
viii. has sufficient accountability to enable business to question and appeal decisions
and to address possible cases of corruption (in line with principle 6)
ix. monitors compliance in order to assess the effectiveness of enforcement
activities
x. is adequately resourced and has the skills to be able to fulfill its responsibilities
Source: MPC, 20144
3.6 Medical Professionals’ Issues/Complaints raised by various stakeholders
Through letter submissions and stakeholder’s consultation, the team was advised
of various employment regulations which impose significant burdens on
businesses. These were further substantiated through the interviews with 3
associations namely Malaysian Medical Association, Malaysian Dental Association
and Malaysian Pharmaceutical Society. Primary research was extended to 4
private practices across all sectors in the country (specifically the team visited a
private clinic which has been in operations for more than 20 years in the Klang
Valley, two dentists operating two separate private practices, the Head of
Pharmaceutical Department of a large private hospital in Kuala and the Manager
of Nurses and Midwives of a small private hospital in Selangor. The team obtained
various feedbacks during the engagements. Table 3-1 below lists the
issues/complaints raised by various stakeholders
4 Malaysia Productivity Corporation (2014), Handbook on Reducing Unnecessary Regulatory Burdens: Core Concept.
45
Table 3.1 : Issues/Complaints raised by various stakeholders
Categories Issues/Complaints
Regulatory
Burdens
1) Personal Data Protection Act (PDPA) that burdens doctors to
register as data user and comply with the annual fees of the Act
2) No coordination in management of the Disposal for Clinical Wastes
3) Third party involvement that constraints doctor practice example
Department of Environment (DoE) and Local Council
4) The requirement for maternity centres to have an in-house
anaesthetist and a paediatrician
5) The specified number of official daily visits to patient by doctor
during hospitalisation
6) Inconsistencies and lack of coordination between ministries such
as MOE and MOH
7) The burdens in complying with Annual Practicing Certificate (APC)
8) The burden in renewal of licensing for private hospital
9) Inefficiencies in labelling of medicines (supplement against
medicine)
10) The lack of private colleges that have their own hospital for training
has resulted in low quality of houseman
11) The intervention of insurance companies/ Medical Care
Organization(MCO) in practice of private medical practitioner
12) The regulation for foreign specialist to practice in Malaysia
13) Restrictions for place of practice for pharmacists (only one place of
practice for pharmacist)
14) Stringent restrictions to advertisement of services
Regulations/
Policies
1) Burden to medical professional in complying with GST
2) Disparity of salary between private and public medical practitioners
Others
1) The requirement by insurance companies that forces medical
practitioners to register with certain bank as a condition to remain
as panel doctors
2) The separation of rules between doctor and pharmacist
3) The shortage in the supplies of specific specialisation of dentist to
meet the health tourism plan
4) Joint Commission International (JCI) not effective in Malaysia
5) Not enough exposure on Health Tourism in Malaysia by medical
professional
In completing this report, emphasis will only be given to issues arising from current
regulations, including by-laws, circulars, orders and guidelines related to the practice
46
of medical professionals in Malaysia. These issues will be discussed in greater length
in Chapter 5, 6 and 7. Some of the listed issues were not pursued due to the following
reasons:
i. The issue focuses entirely on policy, not on the burdens placed to achieve the
policy and nothing could be done to solve it unless there’s a change in the
policy itself. This falls out of the scope of this review which only looks into
reducing regulatory burdens (Reducing Unnecessary Regulatory Burden).
ii. Some of the issues are already under review or have been reviewed by other
Government Ministries or Agencies
iii. Some of the issues are not being pursued due to lack of information to verify
the complaints.
The issues that are being reviewed by the team are grouped under the stages of the
Employment Value-Chain (i.e. Hiring, During Employment and Separation). This
value-chain is covered thoroughly in Chapter 4. Figure 3-1 provides an overview of the
issues being pursued under the review.
47
Figure 3.1: Issues under review
1. Inadequate quality control of private
colleges providing health sciences
education
2. Supplies of clinical training for
housemen and nursing graduates
2. Lack of Regulatory Framework for
MCO Operation
- Minimal fees paid to medical
professionals
- Intervention on clinics operation
- Delayed and partial
reimbursement
- Selective Empanelling and Fee
Splitting
3. Discrepancies between Personal
Data Protection Act 2010 and
PHFSA 1998
- The Redundancy on Confidentiality
- Difficulties to gain access of data of Information
Pre-Qualification
Exit / Termination
48
Chapter 4: Regulations Affecting Medical Professionals in Malaysia
4.0 Regulations Affecting Medical Professionals in Malaysia
This chapter provides an overview of the regulations affecting the medical
professionals in Malaysia. It should be emphasized that the regulations discussed
would cut across the whole healthcare sector and occupations. While this chapter
focuses mainly on the occupational Acts in the healthcare sector, other employment
regulations that may influence HR practices are not included in the review (Box 4-1).
Box 4.1: Employment regulations that may influence HR Practices
i. Employment Act 1955 (Act 265)
ii. Sabah Labour Ordinance- [Sabah [Cap.67]
iii. Sarawak Labour Ordinance - Sarawak [Cap 76]
iv. Trade Unions Act 1959 (Revised – 1982 (Act 262)
v. Workers' Minimum Standards Of Housing And Amenities Act 1990 (Act 446)
vi. Minimum Retirement Age Act 2012 (Act 753)
vii. Employees Provident Fund Act 1991 (Act 452)
viii. Industrial Relations Act 1967 (Revised – 1976) (Act 177)
ix. Holidays Act 1951 (Revised - 1989) (Act 369)
x. Workmen's Compensation Act 1952 (Revised - 1982) (Act 273)
xi. Weekly Holidays Act 1950 (Revised 1979) (Act 220)
xii. Minimum Wages Order 2013
Source: Author
4.1 Regulatory Overview of Medical Professionals in Malaysia
A Medical Professional is someone who provides preventive, curative, promotional or
rehabilitative healthcare services in a systematic way to individuals, families or
communities. A health professional covered under this study may be within medicine,
midwifery, dentistry, nursing or pharmaceutical professions. These professionals are
persons formally certified by a professional body as belonging to a specific profession
within healthcare by virtue of having completed a required course of study and/or
practice, and whose competence can usually be measured against an established set
of standards.
49
For the purpose of this review, the scope will be narrowed down into two main medical
professionals servicing the health industry, which are Doctors and Nurses. Nurses shall
also cover specialised nursing areas including dental nurses and midwives. These
professionals are selected from a list of eight professions as they represent the majority
of the professionals within the industry. They do not only provide services to the health
industry but also other sectors such as education and tourism while also contributing
to the health of all citizens and thus the supply of healthy labour force. Hence, any
improvements in the regulation of these professionals may add value to all sectors and
to social wellbeing.
The roles and description of medical professionals under this study are both legally
and functionally defined, as follows:
Table 4.1 : Roles and description of medical professionals
Roles Descriptions
Doctors
Doctors are persons who are entitled to be provisionally
registered as a medical practitioner (Medical Act 1971, Sec 29).
Functionally, medical doctors examine, diagnose and treat
patients. They can specialise in a number of areas such as
paediatrics, anaesthesiology or cardiology, or they can work as
general practice physicians (CPC Medical Doctors Board of
Malaysia, 2014).
Dentists
Dental practitioners registered in Division II of the Register;
(Dental Act 1971). Functionally, dentists are health care
practitioners who specialize in the diagnosis, prevention, and
treatment of diseases and conditions of the oral cavity (CPC
Dentist Board of Malaysia, 2014).
Pharmacists
Licensed to carry out a business, so far as such business relates
to the keeping, retailing, dispensing, and compounding of
poisons, dangerous drugs or therapeutic substances, in
compliance with a few conditions stated in Registration of
Pharmacists Act 1951 (REVISED - 1989), Poison Act 1952 and
Dangerous Drug Act 1952. Functionally, pharmacists are drugs
experts, responsible in dispensing medications, educating
50
Roles Descriptions
consumers on the use of over-the-counter medicines and
advising other health professionals on drug decisions (CPC
Pharmacist Board of Malaysia, 2014).
Nurses
Person registered as a nurse in accordance with any written law
relating to the registration of nurses for the sick (Midwives Act
1966 (REVISED - 1990)) Functionally, nurses contribute to the
health and welfare of society through protection, promotion and
restoration of health; the prevention of illness and the alleviation
of suffering in the care of individuals, families and communities
(CPC Nursing Board of Malaysia, 2014).
Medical professionals being a party within the professional services industry covers
the activities of various Acts governing the professional codes of conduct. Generally,
there are about 150 Acts governing the practice of Medical Professionals.
The main Acts include:
i. Medical Act 1971 (Act 50)
ii. Dental Act 1971 (Act 51)
iii. Nurses Act 1950 (Act 14) & Nurses Registration Regulations 1985
iv. Registration of Pharmacists Act 1951 (Act 371) & Registration of
Pharmacists Regulations 2004
The main objective of the professional Acts is to govern the practise of professionals
in the interest of the public and the nation. However, there are instances where over-
regulating of these professions have led to unnecessary burdens on the practitioners
and result in higher costs or poorer service to the public. Unnecessarily demanding
Acts, rules and regulations need to be reviewed to make accreditation, career growth
and practice easier and to boost the effectiveness of medical services.
51
Table 4.2 : Medical professional and their professional boards
MEDICAL PROFESSIONAL PROFESSIONAL BOARDS
Doctors Malaysian Medical Council
Dentist Malaysian Dental Council
Nurses Malaysian Nursing Board
Pharmacists Malaysia Pharmacy Board
These bodies are governed by the Ministry of Health Malaysia (MOH) and operate
under specific Codes of Professional Conduct (CPC) as specified in the Medical Act
1971 and related Acts and Licensing requirements as listed below. For this review,
please refer to Table 2.2 for the professionals listed in line no 1, 2, 3 and 5.
Table 4.3 : List of Medical Professionals under MOH, Acts, Regulators and APC.
Source: MPC, 2014
52
4.2 Development of the Medical Professional Regulation Framework
Reported by the WHO, currently, the public sector health services in Malaysia are
centrally administered by the Ministry of Health through its central, state and district
offices. Other government departments also provide health services to specific
populations. The Ministry of Higher Education runs the university teaching hospitals,
the Ministry of Defence has several military hospitals and medical centres and the
Department of Aboriginal (Orang Asli) Affairs provides health services to the
indigenous population in collaboration with the Ministry of Health. The Department of
Social Welfare provides nursing homes for the elderly, the Ministry of Home Affairs
manages the drug rehabilitation centres and the Ministry of Housing and Local
Government provides environmental health services and limited health services, such
as in the Kuala Lumpur Federal Territory. The categorization of these regulators/
government bodies can be seen below in Table 4-3: Value Chain mapped against
Relevant Acts / Regulations.
The value chain covered within the study starts from the stage of acquiring education
until the departure from professional medical practice:
Figure 4.1 : The Value Chain of Medical Professional
In this context, the scope of this review shall cover the following:
Tertiary education required to obtain the first certificate to be certified and to
practise within the field of medicine (minimum requirements, supply vs. demand,
quality);
Placement as junior practitioners (e.g. houseman ship, trainee nurse);
Delivering services (in MOH hospitals or private practices) - Annual Practicing
Certificate (APC) and other requirements;
Qualifying for specialisation (e.g. requirements based on the number of years of
service, demand for specialist and the areas of specialisation);
Pre-Qualification
General Practices &
Specialisation
Exit / Termination
53
The completion or termination of practice.
To understand the current regulations that are governing each step within the Value
Chain, herewith is the list of regulations, Acts and relevant requirements with the
Ministries and Regulators responsible. Each process is mapped against related
regulations, acts and requirements to enable respondents to examine the regulatory
issues that are encumbering each process within the chain.
Table 4.4 : Value Chain mapped against Relevant Acts / Regulations
STAGE ACTIVITIES /
PROCESSES
ACTS &
REGULATIONS REGULATORS
Pre-Qualification
Pre-
Qualifi-
cation
1. Tertiary Education
pre-requisite.
2. Entry into certified
medical schools.
3. Qualifying
Examinations.
Education Act 1996
(ammd. 2006).
MQA Act 2007
Medical Act (1971)
Private Higher
Education Act 555
(1996 amend 2006)
Ministry of Higher
Education (MOHE)
Malaysian Qualification
Agency (MQA)
Ministry of Health
(MOH)
Boards of Each
Medical Professional
General Practices & Specialisation
Service
Entry
1. Comply with
Placement /
Housemanship
requirement in
MOH Hospitals.
2. Restrictions to
overseas graduates
and foreigners.
3. Additional
Requirements for
overseas graduates
from certain
Education Act 1996
(ammd. 2006).
Medical Act (1971)
– Amend 2012
Private Higher
Education Act 555
(1996 amend 2006)
Medical Regulations
1974
Medical (Setting for
Provisional
Registration)
Regulations 2012
Ministry of Higher
Education (MOHE)
Ministry of Health
(MOH)
Ministry of Human
Resource
Malaysian Medical
Council (MMC)
Malaysia Nursing
Board.
Pharmacy Board
Malaysia Dental
Association (MDA)
54
STAGE ACTIVITIES /
PROCESSES
ACTS &
REGULATIONS REGULATORS
countries and
private institutions.
Nurses Act 1950
(Amend 1980)
Medical Qualifying
Exams.
Registration of
Pharmacist Act
1951
Midwives Act 1966
(Rev 1990)
Malaysia
employment Act
1955.
Midwives Board
General
Practition
-ers and
Advance
ment –
Speciali-
sation
MOH Hospitals:
1. Requirements for
entry into practice.
2. Career
advancement-
availability of
patients and cases
to improve
competencies /
Continuing
Professional
Development
(CPD)
3. Requirements to
qualify for
Specialisation.
4. Obtaining
specialisation - field
of study: Fitting
Medical Act (1971)
– Amend 2012
Medical Regulations
1974
Medical (Setting for
Provisional
Registration)
Regulations 2012
Nurses Act 1950
(Amend 1980)
Registration of
Pharmacist Act
1951
Midwives Act 1966
(Rev 1990)
Private Healthcare
Facilities &
Services Act 1998.
PDPA 2013
Ministry of Higher
Education (MOHE)
Ministry of Health
(MOH)
Ministry of Human
Resource.
Ministry of Domestic
Trade, Co-operatives
and Consumerism.
Ministry of Trade and
Industry (Tourist
Development
Corporation-TDC)
Malaysian Medical
Council (MMC)
Malaysia Nursing
Board.
Pharmacy Board
Malaysia Dental
Association (MDA)
55
STAGE ACTIVITIES /
PROCESSES
ACTS &
REGULATIONS REGULATORS
supply with
demand.
5. Code of Conduct
6. Registration and
Licenses to
practice
Private Practices:
1. Qualification to
practice in private
practices.
2. Statutory
Registration.
3. Professional
Registration/
Licenses.
4. Sales of Drugs.
5. Codes of Conduct
:Private Healthcare
Regulations
6. Maintenance and
Administration of
practice location /
professional
license/
registration/
medical
employees.
7. Provide support for
Health Tourism
Malaysian Health
Promotion Board
Act 2006.
Fees Act 1951 –
Fees Medical Rev
1994)
Registration of
Pharmacists Act
1951 (Rev- 1989)
Medicines
(Advertisement &
Sales) Act 1956
(Rev-1983)
Dental Act 1971
Dangerous Drugs
Act 1952 (Rev 1980)
Malaysia Tourism
Board Act 1992
Malaysia
Employment Act
1955.
Medical Devices
Act.
Midwives Board
Malaysia Healthcare
Travel Council (MHTC)
Exit/Termination
56
STAGE ACTIVITIES /
PROCESSES
ACTS &
REGULATIONS REGULATORS
Termina-
tion/ Exit
Exit process
1. While under
contract
2. After contract
expiry
3. Natural attrition
(retirement).
4. Disciplinary – Force
to exit
Medical Regulations
1974
Medical (Setting for
Provisional
Registration)
Regulations 2012
Nurses Act 1950
(Amend 1980)
Medical Qualifying
Exams.
Registration of
Pharmacist Act
1951
Midwives Act 1966
(Rev 1990)
Ministry of Health
(MOH)
Malaysian Medical
Council (MMC)
Malaysia Nursing
Board.
Pharmacy Board
Malaysia Dental
Association (MDA)
Midwives Board
Table 4-4 may not show the full process in delivering the professional services, but it
is intended to assist respondents to gauge the scope of regulatory burden imposed
on these Professionals at every stage of the profession. Professionals may encounter
numerous regulations other than those stated above such as regulations pertaining to
professional fees/ charges, rules in delivering services, contract administration,
professional risk and indemnity, etc. may also be raised. Therefore, additional
information that may be relevant from the respondents’ experience and perspective
are welcomed including suggesting any additional regulations which should be added
to this list.
57
Table 4.5 : Summary of Medical Act 1971
Value Chain Sections Summary Applicable to
Pre-
Qualifications
Section 34A.
Examination
and treatment
of patients by
students of
medicine.
Any person who is pursuing medicine or
surgery in certified institutions (University
Colleges Act 1971 or Third Schedule of
the Act), can only carry out investigation,
examination or treatment of patients in
any hospital, clinic, health centre or other
institution which is approved under the
control and supervision of a fully
registered medical practitioner who holds
a current and valid annual practising
certificate.
General
Practices &
Specialisation
12: Persons
entitled to
provisional
registration
He must hold-
(i) any of the qualifications specified in the
third column of the Second Schedule
; or
(ii) a qualification in medicine and surgery
other than the qualifications referred to
in subparagraph (i),
and
(b) he produces to the Registrar evidence
to the satisfaction of the Registrar that he
is being provisionally registered, and has
been selected-
(i) for employment under section 13(2) or
that he is eligible to be exempted
therefrom under section 13(6).
Housemen
58
Value Chain Sections Summary Applicable to
13: Experience
which a
provisionally
registered
person shall be
required to
obtain
He must engage in employment in a
resident medical capacity to the
satisfaction of the Medical Qualifying
Board for a period of not less than one
year in any hospital or institution in
Malaysia which is approved by the said
Board for the purpose of such
employment; four months of such period
shall be spent in a resident surgical post,
four months in a resident medical post
and four months in a resident obstetrical
and gynaecological post;
Housemen
Section 14:
Persons
entitled to full
registration.
He has been provisionally registered
under section 12; and he furnishes proof
of having satisfied the provisions of
section13.
Medical
Officers
Section 16:
Temporary
practising
certificate.
A person who is registered as a medical
practitioner outside Malaysia must
acquire a temporary certificate to practise
but under allowable maximum period of
three months
Foreign
medical
practitioner/
specialists
Section 20.
Annual
practising
certificate
(APC)
The APC is imposed upon all medical
practitioners. It must be renewed not later
than the first day of December of that year
at prescribed fees. All place/s of practice
must be registered in the APC
For foreigners, only one place practice
is allowed
Malaysian
medical
practitioner
59
Value Chain Sections Summary Applicable to
Section 26.
Privileges of
fully registered
persons and
disabilities of
unregistered
persons.
Only a fully registered medical
practitioners entitled for reasonable
charges for professional aid, advice and
visits and the value of any medicine or
any medical or surgical appliances
rendered
Medical
practitioner
Section 41.
Period of
service in
pursuance of a
notice under
section 40 (1).
A person must serve in a post in a public
service in pursuance of a notice issued
under section 40(1), for a continuous
total period of not less than three years
Medical
Officers
Table 4.6 : Summary of Nurses Act 1950 (Amendment 1969) and Nurses
Registration Regulation 1985
Value Chain Sections/
Regulations
Summary Applicable
to
Pre-
Qualifications
Section 4.
Register of
Nurses
(1) It shall be the duty of the board,
subject to and in accordance with this
Act, to form and keep a register of
nurses for the sick.
Board of
Nurses
Section 6.
Admission to
register of
persons
trained
outside
Malaysia.
(2) If any person proves to the
satisfaction of the Board that he or
she has been trained in anyplace
outside Malaysia where the standard
of training and examination is not
lower than the standard of training
and examination required under this
Nurses
60
Value Chain Sections/
Regulations
Summary Applicable
to
Act, either as a general nurse for the
sick or as a nurse of some special
class, and satisfies the Board as to
his or her identity and good character,
the Board may, either after
examination or without examination,
upon payment of the fee prescribed
for registration under this Act, direct
that that person shall be registered in
the appropriate part or parts of the
Register.
Regulation 13.
Training and
Examination
(1) No person shall be accepted for
training in an approved nurses
training school unless he has passed
the Malaysia Certificate of Education,
the Sijil Pelajaran Malaysia or such
other examination as may be
accepted by the Board.
(2) The nurses training course shall
not be less than three years.
(3) The Board shall hold periodical
and final examinations in subject
prescribed by the Board at such
times, in such places and subject to
such conditions as the Board may
from time to time direct.
Nurses
61
Value Chain Sections/
Regulations
Summary Applicable
to
Regulation 15.
Certificate of
Training
(1) No person shall be entitled to
enter for the nurses final examination
until he has passed the periodical
examinations stipulated by the
Board.
(2) A person who applies to enter for
the nurses final examination shall
deposit with the Secretary of the
Board a certificate
signed by the principal of the training
school in which his training was given
to the effect that -
(a) He has undergone the training
prescribed by the Board as is
necessary to qualify him for
admission to the part of the Register
to which the nurses final examination
relates;
(b) He has undergone systematic
instruction in each of the subject
prescribed in the syllabus of subject
for such examination as approved by
the Board; and
(c) He is of good conduct
Nurses
General
Practices &
Specialisation
Regulation 8.
Annual Nurse
Practicing
Certificate
(1) Any person in the general and
supplementary parts of the Register
who desires to practice after the 31st
December of any year shall, not later
Nurses
62
Value Chain Sections/
Regulations
Summary Applicable
to
than the 30th September of that year,
make an application in the form set
out in the Third Schedule and pay the
prescribed fee for a certificate to
practice as such.
(2) Upon such application and
payment, the Register shall issue a
certificate (to be styled the „annual
nurse practicing certificate‟) set out in
the Fourth Schedule authorizing the
applicant to practice during the year
for which the certificate is issued.
(3) The annual nurse practising
certificate shall be in force until the
31st December of the year in
respect of which it is issued.
(4) It shall not be necessary for a
person who is registered in more than
one part of the Register to possess a
separate annual nurse practicing
certificate for each part.
4.3 Regulators and Other Related Bodies
The regulatory regimes of Medical Professionals in Malaysia are very extensive and
complex as they involve many different ministries, departments and agencies. The
principal regulator is the Ministry of Health. The list of ministries, departments and
agencies are described together in the Employment Life Cycle Value Chain above.
Acts and regulations that are highly related to licensing and permits of professionals
in various sectors as well the safety and health regulations are also described above.
63
However, the primary focus of this report is on the regulatory aspects of occupational
regulation operated by the Ministry of Health (MOH).
Table 4.7 : Roles and Responsibilities of the Ministry of Health and related
agencies affecting the accreditation and practice of medical professionals
Ministry/Agency Roles and Responsibilities
Ministry of Health
To assist an individual in achieving and sustaining as well as
maintaining a certain level of health status to further facilitate
them in leading a productive lifestyle – economically and
socially.
This could be recognized by introducing or providing a
promotional and preventive approaches, other than an
efficient treatment and rehabilitation services, which is
suitable and effective, whilst priorities on the less fortunate
groups.
Malaysian Medical
Council
The core functions of the Council under the statute are as
follows:
Registers only qualified doctors;
Prescribes and promulgates good medical practice:
Promotes and maintains high standards of medical
education; and
Deals firmly and fairly with doctors whose fitness to
practise is in doubt.
To recognize registration of medical practitioners;
To maintain a Medical Register of all registered medical
practitioners in Malaysia;
64
Ministry/Agency Roles and Responsibilities
To issue practicing certificates to registered medical
practitioners;
To promote, recognize and accredit medical education
and training programmes and institutions;
To determine and regulate the conduct and ethics of
registered medical practitioners;
To consider the cases of medical practitioners who,
because of some mental or physical condition, may be
unfit to practise medicine;
To review the competence of medical practitioner;
To advise and make recommendations to the Minister of
Health on matters relating to the practice of medicine in
Malaysia; and
To perform such other functions so as to give effect to the
Medical Act 1971 as may be prescribed in the Act or
assigned by the Minister
Malaysian Dental
Council (MDC)
The Malaysian Dental Council (MDC) has 6 primary functions
by which it serves the dental profession. The functions are:
Upholding and maintaining professional standards and
ethics in the practice of dentistry
Recognition of Dental Degrees
Registration of Dental Practitioners in Malaysia
Issuance of Annual Practising Certificates and Temporary
Practising Certificates
Maintenance of the Malaysian Dental Register
Exercising disciplinary jurisdiction over registered
practitioners
65
Ministry/Agency Roles and Responsibilities
Malaysia Nursing
Board
Malaysia Nursing Board that oversees training and discipline
of nurses to ensure the practice of nursing in the country is
carried out as stipulated under the Nurses Act 1950 & Nurses
Registration Regulations 1985. The practice of nursing
requires specialized knowledge, skill, and independent
decision making. The core function of the Malaysia Nursing
Board is to establish and improve standards of nursing care
to protect the public:-
To keep and maintain the Register of nurses
To regulate the nursing practice
Midwife Board
Malaysia Midwifery Board that oversees training and
discipline of nurses to ensure the practice of midwives in the
country carried out as stipulated under the Midwives Act 1966
& Midwives Regulations 1990. The practice of midwives
requires specialized knowledge, skill, and independent
decision making. The core function of the Malaysia Midwifery
Board is to establish and improve standards of midwifery care
to protect the public:-
Regulate the course of training, conduct of examination,
issue of diplomas, certificate and badges
To regulate the practice of midwifery and conduct of
midwives
66
Ministry/Agency Roles and Responsibilities
Pharmacy Board
Malaysia
Pharmacy Board Malaysia is established in aligned with
section 3, Registration of Pharmacists Act 1951.
The roles and responsibilities of the Pharmacy Board
Malaysia:-
Registration and deregistration of Pharmacists and
Bodies Corporates.
Accreditation and recognition of pharmacy
degree programmes in Higher Learning Institutions.
Approval of premises for provisional training.
Coordinating and monitoring of minimum Continuous
Professional Development (CPD) points for issuance of
Annual Retention Certificate.
Setting and conducting of Pharmacy Jurisprudence
Examination for purpose of pharmacist registration.
Setting standard and monitoring the compliance of
institutions to the Guidelines on Approval
and Recognition of Pharmacy Degree Programme to
ensure the quality of the graduates and also
the institutions offering pharmacy course.
National
Specialist
Register
(non-regulatory
body housing
medical specialist
responsible for
The National Specialist Register will ensure that doctors
designated as specialists are appropriately trained and fully
competent to practise the expected higher level of care in the
chosen specialty. With the National Specialist Register in
place, doctors will be able to identify fellow specialists in the
relevant specialties to whom they can refer either for a second
67
Ministry/Agency Roles and Responsibilities
specialist
registration as
recognized by
MOH)
opinion or for further management. Importantly, the National
Specialist Register protects the public and will help them to
identify the relevant specialist doctors to whom they may wish
to be referred or may wish to consult. The National Specialist
Register is in fact an exercise in self-regulation by the medical
profession, striving to maintain and safeguard the high
standards of specialist practice in the country, having the
interest and safety of the public at heart.
Malaysia
Qualification
Agency (MQA)
under Ministry of
Higher Education
(MOHE)
The establishment of a new entity which merges the National
Accreditation Board (LAN) and the Quality Assurance
Division, Ministry of Higher Education (QAD) was approved
by the Government on 21 December 2005. This entity is
responsible for quality assurance of higher education for both
the public and the private sectors.
The main role of the MQA is to implement the Malaysian
Qualifications Framework (MQF) as a basis for quality
assurance of higher education and as the reference point for
the criteria and standards for national qualifications. Its
members comprises of professionals from various sectors.
The MQA is responsible for monitoring and overseeing the
quality assurance practices and accreditation of national
higher education.
As a quality assurance body, the functions of MQA are:
- To implement MQF as a reference point for Malaysian
qualifications;
68
Ministry/Agency Roles and Responsibilities
- To develop standards and credits and all other relevant
instruments as national references for the conferment
of awards with the cooperation of stakeholders;
- To quality assure higher education institutions and
programmes;
- To accredit courses that fulfill the set criteria and
standards;
- To facilitate the recognition and articulation of
qualifications; and
- To maintain the Malaysian Qualifications Register
(MQR)
69
Chapter 5: Regulatory Burdens at the Pre-Qualifications and Training of Medical
Professionals
1. Inadequate quality control of private
colleges providing health sciences
education
2. Supplies of clinical training for
housemen and nursing graduates
2. Lack of Regulatory Framework for
MCO Operation
- Minimal fees paid to medical
professionals
- Intervention on clinics operation
- Delayed and partial
reimbursement
- Selective Empanelling and Fee
Splitting
3. Discrepancies between Personal
Data Protection Act 2010 and
PHFSA 1998
- The Redundancy on Confidentiality
- Difficulties to gain access of data of Information
Pre-Qualification
Exit / Termination
70
Chapter 5
5.0 Regulatory Burdens at the Pre-Qualifications and Training of Medical
Professionals
As shown in Chapter 4, the scope of the review includes the stage of acquiring the first
certificate to be certified and practice within the field of medicine and obtaining placement
as junior practitioners. It is important for these practitioners to have the required set of
academic qualifications and training requirements. While this chapter focuses on the early
development of medical professionals, this stage impacts on the whole value chain. The
impacts of Government policies, Acts and requirements covered in this chapter are:-
1. Questionable quality of colleges providing health sciences related education
2. Supplies of clinical training for housemen and nurses graduates in the hospitals
Figure 5.1 : The Value Chain of Medical Professionals
In 2007, there were 21 medicals schools in Malaysia, 10 public and 11 private. In 2016,
the country have 28 medical schools, 20 public and 8 private, the list by Malaysian
Medical Council1 as well as 366 other institutions from 36 different countries like United
Kingdom, Singapore, Indonesia, Saudi Arabia, United States of America, etc. In 2014,
there were 8,157 medical students in public universities and 11, 348 in private institution
while 539 others pursued their study abroad2. Most of these institutions cater for medical
doctors, dentists and pharmacists while nurses are trained locally.
1 List of Medical Institution in Malaysia by Malaysia Medical Council (MMC), available at : http://www.mmc.gov.my/v1/index.php/list-of-medical-institution 2?resetfilters=0&clearordering=0&clearfilters=0 2 TheStar (28 April 2016) Restriction on new medical courses to ensure quality of junior doctors, The Star
Online, see: http://www.thestar.com.my/news/nation/2016/04/28/ freeze-extended-by-five-years-
restriction-on-new-medical-courses-to-ensure-quality-of-junior-doctors/
Pre-Qualification
Medical Prof. Trainee
General Practices &
Specialisation
Exit / Termination
71
The rapid increase in the number of medical schools in the country has given rise to some
concern especially on the excess of doctors and the challenge of ensuring quality. The
situation has called for government to announce the moratorium to freeze new medical
courses in local institutions for the next five years effective from 1st May 2016 to 30th April
2021. This is to ensure that there is a balance between the supply offered and the industry
demand, and the marketability of graduates3. Despite the moratorium, the supply of
medical students continues to rise as students decided to seek education from affordable
medical school in other countries such as Egypt, Indonesia and Taiwan. Interviews with
students and parents have shown that the cost to study medicine in Egypt ranges
between RM200, 000 - RM300,000 for the whole duration of studies compared to over
RM500,000 for a medical degree in a private college in Malaysia, making foreign medical
education a more attractive hub. With this trend, Malaysia will continue to have a
significant addition of new doctor every year despite the moratorium.
This study is directed towards addressing the issue of quality. Therefore, more emphasis
is paid on findings related to the quality of medical professionals and the contributing
causes as discussed below:
i. Establishment of the key quality assurance agencies4
One of the causes that affect the quality of medical professionals is the compromised
quality of medical training offered by private colleges in Malaysia. To manage this
problem, the Malaysian government through the Ministry of Education has established
the Malaysian Qualifications Agency (MQA) in 2005, to replace Lembaga Akreditasi
Negara (LAN) or ‘National Accreditation Board’. Its role is to oversee the quality
assurance of universities and colleges. The universalisation of basic education gradually
increased the demand for tertiary education. Several forces served to revolutionise
access to and the provision of higher education. The policy of restructuring the economy
to shift from production-based to knowledge-based, which required skilled manpower,
also drives the growth in private higher education institutions as existing public education
system was insufficiently equipped and staffed to meet demand. The on-going university
3 TheStar (28 April 2016) Restriction on new medical courses to ensure quality of junior doctors, The Star Online, see: http://www.thestar.com.my/news/nation/2016/04/28/freeze-extended-by-five-years-restriction-on-new-medical-courses-to-ensure-quality-of-junior-doctors/
4 HC Chai (2007) in an article ‘The Business of Higher Education in Malaysia, Commonwealth Education Online’, Available at: http://www.cedol.org/wp-content/uploads/2012/02/114-118-2007.pdf (Accessed on 20 April 2015)
72
academic ‘twinning’ programmes provide a perfect solution: parents and the Government
can save money, and students studying in Malaysia can gain academic and professional
qualifications conferred by prestigious universities from Europe, Australia and North
America, while the local private HEIs could profit from the increasing demand for higher
education. Hence, the relevance of MQA as a quality assurance body.
MQA5 is established to :
i. To implement MQF as a reference point for Malaysian qualifications;
ii. To develop standards and credits and all other relevant instruments as national
references for the conferment of awards with the cooperation of stakeholders;
iii. To quality assure higher education institutions and programmes;
iv. To accredit courses that fulfil the set criteria and standards;
v. To facilitate the recognition and articulation of qualifications; and
vi. To maintain the Malaysian Qualifications Register (MQR)
Despite the above, many medical professionals interviewed expressed their concerns
over the supply and quality of graduates in the Healthcare Industry particularly doctors
and nurses. Figure 5.2 summarizes the framework of the chapter which outlines the
process of accreditation of private colleges by MQA and the areas of concern. Inputs are
the main resources involved in the accreditation process. Whilst outputs are the result of
the accreditation process. Outcomes are measured based on the performance and quality
of graduates.
Figure 5.2: Framework of Accreditation Process
5 MQA’s website at : http://www.mqa.gov.my/
i. Syllabus
ii. Student
iii. Professionals iv. Expenditure
PROCESS
i. Accreditation
ii. Teaching &
Learning
OUTPUT INPUT
i. Graduates
ii. Accredited colleges
OUTCOME
Graduates not meeting
industries standards as measured by:
i. Professional Exam
results and
Assessment
ii. Potential
employers’
feedback
Management of
professionals as
accreditors of
syllabus and colleges
by MQA
Discipline of action
(implementation
process)
Lack in effective quality &
compliance measurement,
performance indicators
and enforcement
AREAS OF CONCERN
73
5.1 Issue 5.1 – Inadequate quality control of private colleges providing health
sciences education
5.1.1 The Issues
There are two ministries overseeing the education system of medical professions: the
Ministry of Education (MOE) through MQA and Ministry of Health (MOH). While the roles
of these two ministries differ, respected agencies from these two ministries regularly work
hand-in-hand to produce good education programmes and materials to ensure that the
supply side (MOE’s medical education system) is able to produce talented professionals
who can meet the needs of the demand side (MOH).
Examination on MOHE Act 1996 (Act 555) shows that the MOHE is responsible for the
approval or dismissal of application to establish new private institution in Malaysia. The
institution which is granted with the approval must register with MOHE within five years
from the date of approval. This provides the institution ample time to prepare itself for
registration. However, the Act does not specify any obligation by the institution to acquire
MQA accreditation prior to its registration with MOHE. Such situation may result in weak
quality control of the institution teaching, management and infrastructure maintenance as
the accreditation control is not enforced.
Box 5.1 : Private Higher Educational Institution Act 1996 Amendment 2006
Part V : Registration of Private Higher Educational Institution
Section 24
(1) Every private higher educational institution shall be registered under this Part
(2) An application for registration shall be made to the Registrar General—
(a) within five years from the date of the approval for the establishment of the private
higher educational institution granted under Part III;
(b) on the prescribed form and in the prescribed manner;
(c) accompanied by the prescribed fee; and
(d) together with a comprehensive fee structure to be imposed on students with respect
to each course of study.
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In addition to that, the Act under section 24 subsection 7 also states that the failure to
obtain registration from the ministry does not jeopardise the applicant’s right to submit a
new application to the MOHE.
Box 5.2 : Private Higher Educational Institution Act 1996 Amendment 2006
(7) Subject to subsection (3), where additional information, particulars or documents
required under subsection (4) is or are
not provided within the time specified in the requirement or an extension thereof, the
application—
(a) shall be deemed to have been withdrawn; and
(b) shall not be further proceeded with, without prejudice to a fresh application being
made by the private higher educational institution
In general, it is the role of the Professional boards to control the quality of
courses/institutions for medical professionals, as stipulated in the professional Acts.
However, in this case, it is apparent that the boards have limited control over quality as
the MOHE Act allows institution to operate prior to accreditation form the accrediting body
namely MQA.
Further study on the MQA revealed that there are also limitation of roles by the MQA in
controlling the quality of private institution particularly those offering medical courses. This
seems to be because they have limited resources and coordination. In response, the
Government through various agencies imposes extra regulations to fill in the regulatory
gaps.
Under the MQA Act 2007, programmes of higher educational institutions (HEIs) leading
to professional qualifications require that accreditation be done by or in close
collaboration with professional bodies. These are professional bodies established under
various Acts of Parliament to regulate the profession through licensing of practitioners.
The relationship between professionals with MQA forms a Joint Technical Committee
whose scopes are as per clause 51 of the MQA Act. These programmes include medicine,
75
dentistry, pharmacy, architecture, engineering, nursing and several others. Generally, the
accreditation provided for the programme also means recognition from the professional
bodies.
Nurse training
The Professional Board of Nurses, together with the MOE (via the MQA and the Joint
Technical Committees), administers the development of training faculty curricula and
facilities for nurse training. However, many private institutions providing nursing education
are not affiliated with any hospitals even though the Department of Public Services (JPA)
expects all nurses to perform in a clinical setting, not just teaching and managing.
A local study, “Basic Nursing Competencies for Recent Diploma Graduates” by MOE
revealed that student nurses from such private institutions had difficulty getting clinical
experience. If the regulation of nurses training is not improved, candidates could be
disadvantaged from further career opportunities. To address the possible unemployment
of graduates, a scheme called SL1M (Skim Latihan 1 Malaysia) was introduced on 1st
June 2011 where the private hospital and clinics would employ graduate nurses. They
are subsidized by up to RM2000 per nurse per month to hire nursing graduates under this
scheme, in addition to double tax deduction incentives by the Government.
However, private hospitals have revealed that these graduates are unable to meet the
minimum standards established by hospitals. One hospital said that it could only employ
1 out of 80 candidates, while another hospital said that none of the candidates interviewed
was competent to be employed. These observations are consistent with information
provided by the MPC’s review of private hospitals6 in 2014, which states: “There are also
other non-public listed institutions in this business of medical education. The result is that
we have large number of nurses which the private hospitals do not want because they
found that the quality graduates are not up to their requirements.” (Chapter 6, issue no 2
of RURB Private Hospital Report).
6 Reducing Unnecessary Regulatory Burden (RURB) Private Hospitals (2014), Malaysia Productivity Corporation (MPC)
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Box 5.3 shows and extract of MQA Act 2007 which relates to accreditation process for
institution by MQA as discussed in this chapter.
Box 5.3: MQA Act 2007
43. Provisional accreditation of professional programme or professional
qualification
In the case of provisional accreditation of a local or foreign professional programme or
professional qualification, the Agency shall cooperate and coordinate with the relevant
professional body for the purpose of—
(a) considering an application under subsection 38(1) and granting or refusing to grant
the application under section 39;
(b) conducting an institutional audit under subsection 39(3);
(c) imposing conditions under section 41; and
(d) revocation of the certificate of provisional accreditation under section 42
Chapter 2: Professional Programmes and Professional Qualifications
50. Application for accreditation
(1) An application by a higher education provider for the accreditation of its local or
foreign professional programme or professional qualification which complies with the
Framework shall be made to the Agency within the specified period in the certificate of
provisional accreditation in such form and manner as may be prescribed.
(2) Every application shall be accompanied by such documents, information and fees
as may be prescribed.
(3) The form, manner, documents and fees required under subsections (1) and (2) may
differ as between different professional programmes or professional qualifications.
(4) At any time after receiving an application for accreditation and before it is
determined, the Agency, in consultation with the Joint Technical Committee established
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under section 51, may by written notice require the higher education provider to provide
additional documents and information within a specified period.
(5) Where the additional documents and information required under subsection (4) are
not provided by the higher education provider within the specified period or any such
extended period as may be allowed by the Agency, the application shall be deemed to
be withdrawn and shall not be further proceeded with, without prejudice to the right of
the higher education provider to submit a fresh application.
(6) The Agency shall refer an application under this section to the Joint Technical
Committee which shall then make recommendation to the relevant professional body
under subsection 52(1) for the purposes of accreditation.
51. Joint Technical Committee
(1) A Joint Technical Committee consisting of representatives of the relevant
professional body, an officer of the Agency and such other persons as may be deemed
necessary by the relevant professional body shall be established by the relevant
professional body for the purpose of—
(a) considering an application for accreditation under subsection 50(1);
(b) making recommendations to grant or refuse the application for accreditation
under subsection 52(1);
(c) making recommendations for imposing conditions under section 54;
(d) entering and conducting an institutional audit under subsection 52(3); and
(e) making recommendations for the revocation of accreditation under section
55.
(2) The representatives of the relevant professional body and the officer of the Agency
in the Joint Technical Committee established under subsection (1) may differ as
between different professional programmes or professional qualifications.
52. Power to grant or refuse accreditation
(1) After having considered the recommendation of the Joint Technical Committee
under section 51, the relevant professional body may—
78
(a) approve the granting of accreditation; or
(b) refuse the granting of accreditation, stating the grounds for refusal.
(2) Where accreditation is granted under paragraph (1) (a), the Agency shall issue a
certificate of accreditation to the higher education provider upon payment of the
prescribed fees and shall enter the particulars of the certificate into the Register.
(3) For the purpose of considering an application under subsection 50(1), any officer of
the professional body and the Agency may conduct an institutional audit.
Quality issues faced by medical graduates could be attributed to accreditation processes
and quality compliance audits by the JTC, formed by MQA. The weakness persists at the
point of coordination management between the professionals and MQA which escalates
into quality control during the pre- and post- accreditation processes.
One example of weak administration appeared in the case of Allianze University College
of Medical Sciences (AUCMS), where graduates’ grievances - on the noncompliance of
AUCMS’ facilities and some lectures, staff not being paid, students not receiving their
certificates long after completing a programme and other complaints such as misleading
advertising - were not addressed.7 The college was allowed to continue its operation
despite not meeting the quality standards until it had to cease operation due to financial
problems in 2012. By then it had implicated the education and future of over 2,000
students and 500 staff.
In Malaysia, more than 54% of the private nursing diploma graduates could not find a job
three to four months after graduating in 2010 compared to 21.7% in 2008. Government
statistics also show that despite the increase in the number of graduates who took the
Nursing Board Examinations (7,665 in 2010 compared to 4,025 in 2008) the pass
percentage had fallen from 86.5% to 70.1% during the same period. Those studying in
public institutions had a higher pass rate of between 94% and 99% as compared to
graduates from private institutions8. This phenomenon is alarming not only to the industry
7 University World News ( November 20, 2014) in an article ‘Medical College Closure after London Campus Financing Problems’. Available at : http://www.universityworldnews.com/article.php?story=20141120095240372 8 The Star Online (2012) in an article ‘Nursing job woes cut deep’, Available at : http://www.thestar.com.my/News/Nation/2012/02/03/Nursing-job-woes-cut-deep/
79
but also to the graduates and the Government who have invested an average of RM
50,000 per student in grants and loans to finance the study of nursing. Hospitals have
cited low quality of training and poor attitudes for some nurses as being unemployable.
Concerns are also being raised about the quality of young doctors in Malaysia, with the
country's biggest doctors' association raising the red flag on foreign medical colleges and
also experts’ warning of substandard local training. There is evidence that private medical
colleges impose much lower minimum entry requirements - five Bs at the equivalent of
the O levels, or one A and two Bs at the equivalent of the A levels compared to public
universities which maintain high entry requirement of four As in the Malaysian equivalent
of A levels9. The Malaysian Medical Association (MMA), the main representative body for
all doctors in the country, has called on the Government to review its list of recognized
foreign medical colleges. MMA believes that private colleges that have failed to meet the
government's mandatory standards should have their accreditation withdrawn.
Based on the information discussed, it is apparent that both Act governing the registration
and accreditation of private institution in Malaysia could be improved by examining the
following aspects :
Study a requirement for accreditation between the period of approval and
registration of the institution in MOHE Act 1996 (amendment 2009) in clause 24
subsection 2 and 7 :
Study improvements opportunities for the following in the MQA Act 2007
i. coordination among the responsible bodies
ii. management of JTC by the MQA
iii. resourcing of JTC or the MQA and professional boards
iv. consultation and other feedback mechanisms by MQA with the students, hospitals
and other stakeholders
v. management of complaints and feedbacks by public/stakeholders
9 New Straits Time ( November 26, 2013) in an article ‘Experts worry over quality of young doctors in Malaysia’. Available at: http://www.thejakartapost.com/news/2013/11/26/experts -worry-over-quality-young-doctors-malaysia.html
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5.1.2 Objective of MOHE Act 1996
An Act to provide for the establishment, registration, management and supervision of,
and the control of the quality of education provided by, private higher educational
institutions and for matters connected therewith.
5.1.3 Objective of MQA Act 2007
An Act to achieve the following objectives:
(a) To establish the Malaysian Qualifications Agency as the national body to
implement the Malaysian Qualifications Framework,
(b) To accredit higher educational programmes and qualifications,
(c) To supervise and regulate the quality and standard of higher education
Providers
(d) To establish and maintain the Malaysian Qualifications Register and to
provide for related matters
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5.1.4 Options to resolve the issues
1. Status quo
If the status quo is maintained the costs will be high to public and private
hospitals, medical students, patients and the reputation of Malaysia’s health
system with adverse consequences for health tourism.
2. Government to reexamine the MOHE Act 1996 and the enforcement of MQA
Act
This is to ensure the quality of syllabi, training facilities and consultants, and the
availability of clinical training provided by private colleges for medical
undergraduates meet the quality standards thus produces graduates who meet
the industry standards.
The Government is also suggested to review the cases of private colleges, for
example AUCMS, Masterskills and others, to discover factors of failures and
lessons that could be applied in the future. The MOHE should strengthen its
control over application from institution who have failed to comply with the
requirement set by the Ministry and accreditation body. Currently, the MOHE Act
under clause 24 subsection 7 does not address such control measure.
Concerns of the students, staffs and other stakeholders should be taken into
account from time to time in order to find out the actual satisfactory level of these
people and whether the private colleges are not abusing their power. It is
suggested here that the enforcement by MQA should not only refer to the
documentation prepared by the colleges, it should also include consultation
procedures with other stakeholders as stated in the MQA Act Section 6 Function
of the agency subsection 2 as below:
(b) To accredit programmes, qualifications and higher education providers;
(c) To conduct institutional audit and review of programmes, qualifications and
higher education providers;
(d) To establish and maintain a register to register programmes, qualifications
and higher education providers;
(e) To conduct courses, training programmes and to provide consultancy and
advisory services relating to quality assurance;
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3. Benchmark International accreditation
This option suggests that MQA to obtain accreditation from the Programme for
Recognition of Accrediting Agency10. The programme was established in 2010 by
the World Federation for Medical Education (WFME) in collaboration with
Foundation for the Advancement of International Medical Education and
Research (FAIMER). This Recognition Programme11 is a robust and transparent
process that uses globally acceptable criteria to evaluate and recognize the
agencies worldwide that accredit medical schools.
With the increase of private colleges offering medical-related programmes as well
as increase in number of foreign students in Malaysia, having international
recognition will bring added value to various stakeholders. The students from
medical schools that are recognized by accreditation bodies under the
Programme would be able to sit for the Educational Commission for Foreign
Medical Graduates (ECFMG)12 examination. ECFMG through its program of
certification assesses whether physicians graduating from these schools are
ready to enter programmes of graduate medical education for example residency
and fellowship in the United States. This is also in compliance to the requirement
set by the Commission that beginning in 2023, ECFMG will require physicians
applying for ECFMG Certification to graduate from a medical school that has
been appropriately accredited. MQA, with active collaboration at national and
international levels on accreditation and standards setting will be able to ensure
that that the country maintain its education credibility and at the same time
promotes the country as a trusted educational hub at the international level.
10 MMA (2016) Medical Education in Malaysia, see:
http://www.mma.org.my/images/pdfs/President_Message/PM-Feb-16.pdf 11 WFME (2016) FAIMER®: Foundation for Advancement of International Medical Education and Research: Programme for Recognition of Accrediting Agencies, see: http://wfme.org/about/other-wfme-
partners/faimer 12 ECFMG (2016) About ECFMG Certification, see: http://www.ecfmg.org/certification/index.html
83
4. Synchronising the list of approved medical school
This option suggests to synchronize the list of approved medical school (Second
Schedule) between the Ministry of Higher Education (MOHE), Ministry of Health
(MOH) and scholarship providers. By doing this, the government could prevent
the students from entering medical universities or colleges that are not up to the
required standard. The list should be reviewed form time to time in order to ensure
it reflects the current and future requirement in healthcare industry.
5.1.5 Recommended option
Option 2 & 4:
2. Government to improve the enforcement of MQA Act
4. Synchronising the list of approved medical school
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5.2 Issue 5.2 - Supplies of clinical training for housemen and nursing graduates
in the hospitals are not sufficient to meet the requirements of the Act
5.2.1 The issues
Internship for all fields of medical practice makes an important part of every medical
professional’s training as stipulated in Section 13 of the Medical Act 1971 (Experience
which a provisionally registered person shall be required to obtain). It is based on this
spirit that the internship training is developed, to provide fresh medical graduates with
sound experience that professionalises them with appropriate knowledge, skills,
experience and attitudes before awarding them the Provisional Registration. Under the
Medical Act 1971, the Medical Qualifying Board consisting of Director General of the
Ministry of Health (MOH) and equal number of representatives from Faculty of Medicine
of the universities established under the Universities and University Colleges Act 1971
was established to look into matters pertaining to houseman training. This includes:
Evaluate and approve hospitals as housemen training centers
To decide on standards and criteria of housemen training module; and
Approve application for full registration13 based on training experience.
Figure 5.4 illustrates houseman or clinical training as the bridging avenue between a
partial registration of medical professionals and full registration with the Council.
Figure 5.4: Statutory Requirement
Houseman or clinical training has been classified as a compulsory requirement in the
Medical Act 1971 (Section 13),Which is also a standard requirement for medical
professionals in other parts of the world including in countries like Australia, UK, Ireland,
13 Fully registered means fully registered under the Medical Act 1971
Registration with the Malaysia Medical Council
(MMC)
- Provisional Registration
Pratice as house officerFullfill the training criteria
& entitled for Full Registration Certificate
85
USA and the Middle East 14. However the way the overall program of academic and
practical medical training is structured may differ in each case.
Details of clauses on houseman under the Medical Act 1971 are as exemplified below:
BOX 5.2 : Medical Act 1971
Clauses stating requirements for medical training for various medical professionals
Section 13 Experience which a provisionally registered person shall be
required to obtain
(2) The provisionally registered person shall, immediately upon being provisionally
registered, engage in employment in a resident medical capacity to the satisfaction of
the Medical Qualifying Board for a period of not less than one year in any hospital or
institution in Malaysia which is approved by the said Board for the purpose of such
employment; four months of such period shall be spent in a resident surgical post, four
months in a resident medical post and four months in a resident obstetrical and
gynaecological post; at the conclusion of satisfactory service, as certified by the
Medical Qualifying Board, under this paragraph, the provisionally registered person
shall be entitled to a certificate issued by the Council in the prescribed form as
evidence thereof.
BOX 5.3 : A Guidebook for House Officer
Clauses stating requirements for medical training for various medical professionals
2.4 The Structure of Internship Training
The Medical Qualifying Board has determined that:
i. The Committee for the Houseman Training has the right to determine the houseman
discipline placement and the duration of your extension;
ii. The houseman will only be allowed to proceed to the next discipline if the supervisor
is satisfied with your knowledge, skills, competency and attitude in that particular
discipline;
14 Wikipedia, http://www.amc.org.au/accreditation/prevoc-standards, https://www.medicalcouncil.ie/Registration-Applications/First-Time-Applicants/Internship-Registration.html
86
Clauses stating requirements for medical training for various medical professionals
iii. There should not be a gap of more than 4 (FOUR) months between postings.
Otherwise the houseman may need to repeat the entire internship training;
The houseman to undertake four-monthly postings in medicine, paediatrics,
surgery, orthopedic, obstetrics & gynaecology and emergency medicine
The postings in the six disciplines should provide opportunities for you to
participate in:
- assessment and admission of patients with acute medical problems;
- management of in-patients with a range of general medical conditions;
- discharge planning, including preparation of a discharge summary and other
components of handover to a general practitioner or a subacute or chronic
care facility; and
- ambulatory care.
i. You are not allowed to move to another training hospital either to complete or repeat
similar discipline. Only in exceptional circumstances, you may be allowed to
continue internship in a new discipline in another training hospital.
ii. The total duration of each discipline should not exceed 12 (TWELVE) months;
iii. The total duration of your internship training should not exceed 6 (SIX) years;
iv. If you do not satisfactorily complete any or all of the internship training requirements
within the stipulated period, your training shall be discontinued and you will not be
eligible for full registration;
Despite the requirements stated under the Act, there is evidence that medical graduates
lack the experience required. Some medical professionals considered that the problem
lies with the insufficient training available to housemen in the government hospitals. This
may be because of the number of graduates looking for housemen continues to surpass
the growth of training hospitals. The numbers of graduates requiring training increased
from 3,655 in 2013 to an estimated of 5,000 graduates in 2015 - an increase of 36%,
while the number of public hospitals approved by the Medical Qualifying Board for the
purpose of houseman training remain at 44 or 30% of a total of 141 public hospitals
87
nationwide. Due to the limited number of houseman training hospitals, fresh graduates
now have to wait to up to nine months to do their houseman training in government
hospitals which includes 4 months in resident surgical post, 4 months in resident medical
post and 4 months in a resident obstetrical and gynaecoligy posts.15
Malaysian Medical Association (MMA) president, Dr. Krishna Kumar, said that with
medical graduates now being given the choice to choose the hospitals to be trained in
under the e-houseman system and the long waiting lists in some hospitals, the waiting
time could be longer. Prior to the e-houseman system, which was introduced in 2015, the
average waiting time was about six months. Dr. Krishna also added that the waiting time
is getting longer especially in the more popular urban hospitals, including the Kuala
Lumpur Hospital16. According to Health Ministry records, there were 3,564 medical
graduates reporting for duty as housemen in 2011, 3,743 (2012), 4,991 (2013) and 3,860
(2014). Additionally, 30% of housemen do not finish their training in the stipulated period
and need to extend their training between three to six months, depending on the hospital
and taking up the posts for new intake17. The bottleneck is reaching a “critical stage” as
graduates are required to sit for entrance exam, and at the current rate of 5,500 medical
students graduating each year, all 44 training hospitals in the country will face difficulties
in coping with the numbers18.
15 Section 13, Medical Act 1971 16 The Star Online ( March 30, 2015) in an article ‘New docs have to wait a year for housemanship’. Available at http://www.thestar.com.my/News/Nation/2015/03/30/New-docs-may-have-to-wait-a-year-for-
housemanship/ 17 The Malaysian Insider (July 18,2015) in an article ‘Too many medical grads, too few housemanship spots’. Available at http://www.themalaysianinsider.com/malaysia/article/too-many-medical-grads-too-few-
housemanship-spots#sthash.9HjFMU8W.dpuf 18 The Star Online (March 30, 2015)in an article ‘New docs have to wait a year for housemanship’. Available at http://www.thestar.com.my/News/Nation/2015/03/30/New-docs-may-have-to-wait-a-year-for-
housemanship/
88
Figure 5.5 : Statistics of Housemen from 2011 to 2014
Source:MOH’s website
Deputy Health Director General, Datuk Dr S. Jeyaindran said about 1,000 of the 5,000
housemen employed each year do not complete the two-year training stint19. Among the
reasons include not being suitable for the profession as they were pressured to study
medicine by their parents, false perception of a doctor’s work life, inability to work long
hours and burnout. As the housemen are hired by JPA, the termination process must
follow Public Officer (Appointment, Promotions and Termination of Service) Regulation
2012. Table 5.1 below shows the process of termination and hiring as per the regulation.
The process flowchart indicates that the whole termination and hiring process could take
up 180 days to more than a year, resulting in a longer waiting time for new houseman to
take up the vacancy20. The longer waiting time is also due to the training period that vary
from 2 – 6 years. The housemen are allowed to extend one discipline in the event where
they are not able to satisfactorily complete the training in particular discipline (refer to Box
5.2).
19 The Star Online (March 30, 2015) in an article ‘Housemen do not complete training stint for various reasons’. Available at http://www.thestar.com.my/News/Nation/2015/03/30/One-in-five-quit-each-year-
Housemen-do-not-complete-training-stint-for-various-reasons/ 20 The Star Online (March 30, 2015) in an article ‘Housemen do not complete training stint for various reasons’. Available at http://www.thestar.com.my/News/Nation/2015/03/30/One-in-five-quit-each-year-
Housemen-do-not-complete-training-stint-for-various-reasons/
0
1000
2000
3000
4000
5000
2011 2012 2013 2014
3564 3743
4991
3860N
o o
f H
ou
se
me
n
Years
Number of Housemen from 2011 to 2014
89
In addition to the number of training hospitals, shortages also occur in the availability of
consultants, particularly specialist doctors available to provide training. The interviewed
medical practitioners expressed concerns on the ratio of consultants to housemen, which
could reach a ratio of up to 1 consultant to 50 housemen. With these housemen already
lacking in clinical skills and exposure to some procedures they ought to have obtained in
medical schools, this ratio could adversely affect the quality of medical professionals in
Malaysia. Dr. Krishna cited two examples. At the obstetrics and gynecology (O&G)
department in Seremban Hospital, 65 housemen have come under the supervision of two
consultants and five specialists, while the Kuala Pilah Hospital O&G unit only had one
obstetrician overseeing about 30 housemen21.
In addition to the shortage of training consultants, the increasing number of new
graduates also faces lack of clinical training due to limited patient number. The previous
president of Malaysian Medical Association (MMA), Datuk N.K.S Tharmaseelan,22 stated
that in the early 1980s, the ratio of housemen to patient beds was 1:20, however the ratio
had decreased to 1:3 patient beds in 2013. He also said that the ratio of housemen to
beds in developed countries such as Singapore and United Kingdom are 1:8 and 1:12
respectively. This suggests lack of medical cases for housemen to treat.
Training Placement for Nurses
BOX 5.4 : Nurses Act 1950
Student Nurses
Section 3 of Nurses Act 1950: Establishment and constitution of a Nursing Board
The Nursing Board Malaysia (NBM) is the body that regulates the nursing profession.
The main functions include:
1. Maintain a register of qualified nurses through nursing licensure.
21 The Star Online (March 30, 2015)in an article ‘New docs have to wait a year for housemanship’. Available at http://www.thestar.com.my/News/Nation/2015/03/30/New-docs-may-have-to-wait-a-year-for-
housemanship/ 22 New Straits Times (November 17, 2013) in an article ‘More Centres needed to train housemen’. Available at: http://www2.nst.com.my/nation/general/more-centres-needed-to-train-housemen-1.403124
(Accessed on 15 April 2014)
90
2. Set professional standards and guidelines for all levels of nursing education,
nursing practices, management and research.
3. Regulate the conduct and competency of nurses.
4. Evaluate, approve and accreditate all nursing programmes offered locally by both
Public and Private Educational Institutions.
The Guidelines on Standards & Criteria for Approval/Accreditation of Nursing
Programmes stated that the clinical practice areas should cover all required discipline
as approved to meet the learning. The required discipline for Basic Degree and Diploma
are as follow:-
i. Medical nursing
ii. Surgical nursing
iii. Orthopaedic
iv. Paediatric
v. Obstetric
vi. Gynaecology
vii. Ophthalmology
viii. Ear, Nose and Throat
ix. Psychiatry
x. Oncology
xi. Accident and Emergency
xii. Operation Theatre Unit
xiii. Urology
xiv. Geriatrics
xv. Nephrology
xvi. Community Health Nursing
xvii. Optional discipline
a. ICU
b. CCU
c. Neurology
* Note : minimum : 52 - 53 weeks of clinical placement
* Medical nursing & Surgical nursing : 60% of total disciplines
* Management practice : minimum 2 weeks
* Old folk’s home and retirement home are not to be used as clinical practice area
(except for social responsibility)
For clinical placement at hospital facilities;
91
1. At any one placement, the students: CI ratio should not exceed 1:15 and based
on the number of beds in the ward and placement must correspond to the level
of care taught.
2. Ratio of student to patients should be 1:4. Level of patient care must correspond
with the students’ required learning outcomes.
3. Number of students per shift should not be more than 10 per area/ unit/ ward at
any one time regardless of institutions.
4. There must be evidence that respective health care facilities have a planned and
coordinated clinical placement schedule from all institutions to prevent congestion
of students at any one time in any clinical area.
5. Male students must be chaperoned by a female health personnel when attending
to female clients.
For clinical placement at Community Health Centres
1. Number of students allowed per clinic should not exceed 8 at any one time.
2. Number of students per activity in the clinic should not exceed 4.
3. Staff: Student ratio must be 1:8 in clinic and 1:4 during activities.
Similarly in 2010, the Ministry of Higher Education23 put a moratorium on private nursing
colleges to prevent an oversupply of nurses. The move intended to prohibit the launch of
new diploma programmes in nursing as the ministry wants existing providers to
concentrate more on degree courses as well as to prevent the issue of nurse
unemployment. In 2012, the Ministry of Human Resource announced that about 8,000
graduates from nursing institutions especially those from private colleges, are jobless.
The same concerns were raised by the respondents24. The increasing number of nurses
does not only affect supply for employment but also the capability to train these graduates
with the required clinical skills and experience.
23 The Star Online (2010) in an article ‘No more nursing schools from July’ . Available at: http://www.thestar.com.my/story/?file=%2F2010%2F4%2F27%2Fnation%2F6134707 (Accessed on 15
April 2014) 24 The Star Online (June 8,2012)in an article ‘ About 8,000 graduates from nursing colleges are jobless’, Available at: http://www.thestar.com.my/News/Nation/2012/10/08/About-8000-graduates-from-nursing-
colleges-are-jobless/ (Accessed on 15 April 2014)
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5.2.2 Options to resolve the issues
1. Status quo
As the number of medical graduates increase, the longer it takes for the graduates
to enter houseman programme thereby slowing their career development and limit
their opportunities for specialisation. They are also at risk of losing their medical
knowledge that they have learned in previous years.
2. New system for doctor registration
Introduce a new system for doctor registration before qualifying them for
housemanship, by introducing a national registration exam. This is similar with the
requirement imposed by advanced country like US and Japan where medical
graduates must show evidence of medical qualification from accredited
universities, sit and pass the national qualifying exam before being placed for
housemanship. This option will help to
I. Ensure that only qualified and capable medical graduates are being
placed in houseman programme hence putting some control
measure into the quality of medical practitioner treating patient in the
country;
II. Control the number of houseman per hospital or being placed under
supervision of specialist doctors to enhance quality of training,
exposure to patient and case treatment and enable specialist doctors
to better manage or supervise houseman under their care.
3. Houseman be hired based on contract basis
To improve quality and content of houseman training, the MOH and JPA should
revise the employment scheme of trainee doctors. In this option, it is recommended
that houseman be hired on contract basis and will only be absorbed into the
permanent JPA employment scheme upon successfully completing housemanship
or upon registration as medical practitioner (RMP). This approach will ease the
hiring and termination process of houseman. Thus, reducing the waiting time for
hiring new trainee and providing replacement for those who failed to undergo
93
housemanship. In addition, 30% of housemen do not finish their training in the
stipulated period and need to extend their training between three to six months,
depending on the hospital and taking up the posts for new intake25.
In Healthcare Consultative Panel dated 26th July 2016, it was mentioned that
almost 50% of housemen failed to complete their training due to lack of
competencies.
The option could also reduce the problem of termination. From a consultation with
medical practitioner in public hospital, it has been found that there’s a delay in
terminating underperformed housemen. The delay may be from 6 months to up to
2 years, thus resulting to increase in backlog in the new housemen hiring pipe line.
If trainees are put under temporary or contract basis, the process of termination for
those who do not comply with any discipline matter should be shorten and the
responsibilities should fall under the housemen training hospital.
4. Increase the availability of clinical training for houseman.
In order to resolve the shortages of houseman training facilities, MOH should look
into increasing the number of houseman facilities from 44 currently to 52 by 2017
(increase by 20%). This research would like to recommend that houseman
numbers be based on the number of specialist per hospital. This includes placing
trainee in district or smaller hospital with qualified specialist. To manage the level
of exposure to different medical cases and patient numbers, the Ministry could
introduce a rotation system where houseman can be rotated among houseman
centre or hospital in different facility areas. This is further supported because the
size of number of patient can not reflect load of the hospital. Loading also depend
on processes, speed of discharge, patient administration and staff efficiency.
Moreover, the government could also benchmark the guideline of Commonwealth
Medical Internships Programme Guidelines by the Department of Health,
25 The Malaysian Insider (July 18,2015) in an article ‘Too many medical grads, too few housemanship spots’. Available at http://www.themalaysianinsider.com/malaysia/article/too-many-medical-grads-too-few-
housemanship-spots#sthash.9HjFMU8W.dpuf
94
Australian Government26. The programme was initiated in August 2013 with the
intention to assist private hospitals to provide internships and ultimately resolve the
bottlenecks and shortages of placement in the country. The guideline covers the
following aspects:-
Background and requirement of the programme
Roles and Responsibilities of the parties involved i.e. Department of Health,
Private Hospitals and the interns
Eligibility of both the private hospitals and interns
Processing of applications, and
Assessment of interns and the private hospitals.
This practice has been implemented by the Pharmacist Board Malaysia27. In
addition to the 69 public hospitals, the Pharmacist Board Malaysia has recognized
96 private premises as training placement for the provisionally registered
pharmacist (PRP) under the private programme.
5. Getting credit for voluntary participation with medical services
Qualifying students to obtain credit for participation with medical services
organization such as Malaysian Medical Relief Society (MERCY Malaysia),
Malaysian Medical Fellowship and etc. This would help to prevent graduates from
losing medical skills and knowledge while waiting for housemen placement at a
recognized hospitals which could take up to 6 months.
26 Department of Health (2016) Commonwealth Medical Internships Programme Guidelines, Australian
Government, see: http://www.health.gov.au/internet/main/publishing.nsf/Content/work -commonwealth-medical-internships-programme-guidelines 27Pharmaceutical Services Division (2016) Guidelines on Liberalisation of Provisionally Registered
Pharmacist training on private sector for graduates of pharmacy degree programme, MOH
95
5.2.2 Recommended option
Option 2: New system for doctor registration
Option 3: Houseman be hired based on contract basis
96
Chapter 6: Managed Care Organization (MCO)
1. Inadequate quality control of private
colleges providing health sciences
education
2. Supplies of clinical training for
housemen and nursing graduates
2. Lack of Regulatory Framework for
MCO Operation
- Minimal fees paid to medical
professionals
- Intervention on clinics operation
- Delayed and partial
reimbursement
- Selective Empanelling and Fee
Splitting
3. Discrepancies between Personal
Data Protection Act 2010 and
PHFSA 1998
- The Redundancy on Confidentiality
- Difficulties to gain access of data of Information
Pre-Qualification
Exit / Termination
97
6.0 Managed Care Organization (MCO)/ Third Party Administrator (TPA)
In Private Healthcare Facilities and Services Act 1998 Part XV, the Managed Care
Organization (also known as Third Party Organization (TPA) and Health Maintenance
Organization (HMO)) is defined as any organization or body, with which a private
healthcare facility or service has a contract or an arrangement (or intends to have a
contract or an arrangement) to provide specified types or quality or quantity of
healthcare within a specified financing system through one or a combination of the
following mechanisms:
a) delivering or giving healthcare to consumers through the organization or
the body's own healthcare provider or a third party healthcare provider in
accordance with the contract or arrangement between all parties
concerned;
b) administering healthcare services to employees or enrollees on behalf of
payers including individuals, employers or financiers in accordance with
contractual agreements between all parties concerned
The United States National Library of Medicine defined Managed Care as
programmes or organisations “intended to reduce unnecessary health care costs
through a variety of mechanisms, including: economic incentives for physicians and
patients to select less costly forms of care; programmes for reviewing the medical
necessity of specific services; increased beneficiary cost sharing; controls on inpatient
admissions and lengths of stay; the establishment of cost-sharing incentives for
outpatient surgery; selective contracting with health care providers; and the intensive
management of high-cost health care cases.
The first MCO in Malaysia was established in 1995 which is Pantai Medical Care1.
As at 2016, there are 29 registered MCOs in Malaysia (as per Table 6.1) with the
intention to assist in reducing costs which include monitoring, receiving, auditing and
consolidating all medical bills from panel clinics, specialist clinics, hospitals or insurance
company prior to billing the company (payer). MCO will monitor medical benefits usage
1 PM Care (2014) MCO in Malaysia; see: http://www.pmcare4u.com.my/html/whyus.htm
98
to ensure that employees receive the required medical service from their panel clinics
and hospitals2.
Table 6.1: MCOs in Malaysia
No MCO No MCO
1 American International Assurance
Bhd 16 Mediscreen Sdn. Bhd.
2 ASIA Assistance Network (M) Sdn
Bhd 17 MiCare Sdn. Bhd.
3 ASP Medical Clinic Sdn Bhd 18 P.C.S. Rakyat Sdn. Bhd.
4 Cresent Solutions 19 PMCare Sdn. Bhd.
5 Compumed Services Sdn. Bhd. 20 PR Aassist Medical Network Sdn.
Bhd.
6 Cynergy Care Sdn. Bhd. 21 Prudential Assurance Malaysia
Berhad
7 Datalink Healthcard Network Sdn.
Bhd. 22 Red Alert Online Sdn Bhd
8 Eximus Medical Administration
Solutions (E-MAS) 23 Tele Assist Sdn. Bhd.
9 FWHS Medik Sdn Bhd 24 Tejani Emergency Assistance (M)
Sdn. Bhd.
10 Great Eastern Life Assurance
(Malaysia Berhad) 25 Mondial Assistance
11 Health Connect Sdn Bhd 26 IA Assistance
12 International Medicare Group Sdn.
Bhd. 27 MCO Care
13 International SSOS (Malaysia) Sdn.
Bhd. 28
FOMEMA (UNITAB MEDIC SDN
BHD)
2 National Human Resource Centre (NHRC) (2012), Health Maintenance Organisation (HMO) (Also known as Managed Care Organisation (MCO)/Third Party Administrator (TPA)), see: http://www.nhrc.com.my/health-maintenance-organisation-hmo-also-known-as-managed-care-organisation-mco-/third-party-administrator-tpa- )
99
14 Integrated Healthcare Management
(IHM) 29
E-Clinic Online Technology Sdn.
Bhd. (Klinik Alam Medic)
15 MediExpress (M) Sdn. Bhd.
Source: MOH, 2016
In 1997, Malaysian MCOs had a total enrolment of approximately 300,000 or about
1.5% of an estimated population of 20 million. These MCOs covered about 10% of the
private labour force (Pilus, 1999) (Bakar, 1999). However by 2014, the number had
increased significantly, marking an increasing role of MCOs in the country. It is
estimated that over 16.36 million (2014) population are covered under MCOs operations
(10% of private sector employees who are under the TPA and 15 million personal
insurance policy subscribers3 in 2014). Figure 6.1 summarizes the type and functions
of MCOs in Malaysia.
3 Star Online, Tan Kay How (2014) ,Malaysian Grossly Underinsured, see : http://www.thestar.com.my/news/community/2014/12/05/msians-grossly-underinsured-only-half-of-population-have-some-form-of-life-insurance/
100
Figure 6.1: Summary of the Type and Function of MCOs.
While the MCOs can be recognized under various forms (for example, the HMOs, TPAs,
Preferred Provider Organisations, Exclusive Provider Organisations, Primary Care
Preferred Provider Organisations), the HMOs and TPAs are the most common type of
MCO in Malaysia positioning themselves as one of the notable players in healthcare
industry.
Employer (Organisation
Companies)
Managed Care
Organisation
Health Maintenance Organisation
(HMO) - It’s an organized health care
systems that are responsible for both
the financing and the delivery of a
broad range of comprehensive health
services to an enrolled population.
HMO can be viewed as a combination
of a health insurer and a healthcare
delivery management system
Third Party Administrator
(TPA) – a person who directly or
indirectly underwrites, collect
charges, collateral or premiums
from, or adjusts or settles claims
of the population, in connection
with life, annuity, health, stop-loss
or worker’s compensation
coverage.
Inpatient Providers Primary Care Providers
Specialists/Other
providers
Type & Function Type & Function
101
Subsequently in 20134, the Ministry of Health (MOH) identified four categories of MCOs
in the Guidelines for MCOs and Private Healthcare Facilities and Services:-
i. Any organisation including insurance companies (via letter of guarantee) or their
subsidiaries having a contract or an arrangement with any private healthcare
facilities or services to provide healthcare services to enrollees or employees
ii. Any third party or agent for local or overseas-based insurance companies having
a contract or an arrangement with any private healthcare facility or services to
provide healthcare services to enrollees or employees
iii. Any third party administrator managing the medical benefits of personnel in a
company and having contract or an arrangement with any private healthcare
facility or services to provide healthcare services to the employees
iv. Any organisation selling membership for clients to take part in any wellness
package and enters into a contract or makes an arrangement with selected PHFS
to provide healthcare to these members.
The market segmentation of MCO is reflected below in Figure 6.2 which indicates the
mode of payment used by the patients in primary care clinics. It can be seen from Figure
6.2, the percentage of Third Party Payers increases with the decrease of Out-of Pocket
Payment mode which also indicates that the market segmentation for MCO is getting
larger as the Insurance users increase over the years. As such, this chapter would
highlights the regulatory concerns of the healthcare professionals concerning the
Managed Care Organisations in the country.
4 Ministry of Health (2013) The Guidelines for Managed Care Organisations and Private Healthcare Facilities and Services
102
Figure 6.2: Mode of payment in primary care clinics in 2010 and 2012
Source: Clinical Research Centre, MOH 20155
Despite the information on various types of MCOs presented earlier, it is important to
establish that this study focuses on the MCO operating on the TPA model. This is
because insurance companies or the HMOs are governed by the Federal Bank Act,
whilst this study pays a bigger emphasis on the medical and PHFSA Acts governing the
practice of medical professionals.
6.1 Issue 6.1 - Minimal fees paid to medical professionals
The encumbrance of being a panel clinic for private organization under a third party
administrator is significant and does impose burdens to Medical Professionals.
The operation of MCO is currently regulated under the Private Healthcare Facilities and
Services Act 1998. Section 82 to 86 clearly address all relevant matters. Section 83 of
the Act addresses contracts between private healthcare facilities or services and
managed care organisations and the penalties if either party commits an offence whilst
5 Clinical Research Centre (2015) National Medical Care Statistics Primary Care, 2010 & 2012, Ministry of Health (MOH) see: http://www.crc.gov.my/nhsi/category/medical-care-statistics/
57
36
20
32
2232
0.21
2010 2012
Perc
enta
ge
Mode of Payment
Out of Pocket Government Subsidy Third Party Payer Out of Pocket & Third Party Payer Others
103
Sections 84 and 85 covers the need to furnish information to the Director General and
penalties if either party fails to provide such information.
Deep diving into the regulation, the study discovers that there is no clear control over
the practice of MCOs. Section 83 of the PHFSA only emphasizes on the accountability
of RMPs to ensure that the contract they sign with MCOs does not interfere with their
roles as imposed by the respective Board. In addition, Section 86 of the same Act,
merely explained the contractual relationship between MCOs and registered medical
professionals, without mentioning any specific responsibilities of MCOs in delivering
services to the medical professionals, their focus on ethical conduct and the importance
of safeguarding patients’ interest. The MCO Guideline 2013 (Clause 5) again
emphasizes on RMPs’ responsibilities in ensuring that the contract they enter must
safeguard their professional rights and is not conflicting with their Code of Professional
Conduct.
It is only in Clause 6: Guidelines for MCOs that the responsibility of MCO is written in a
bigger perspective. However, the Guideline has no legal influence over the subject,
which is the MCO. Such situation results in a weak control over MCOs operations and
their emphasis over cost savings and profits rather than looking after the welfare of the
patients. This is supported by various statements which raised their concerns over the
regulatory arrangements of MCOs6. Many believe that the regulatory framework on
MCO practice in Malaysia is weak and does not impose adequate control over its
implementation.
61- Dr. Steven Chow, the President of the Federation of Private Medical Practitioners’ Associations, Malaysia ,2013 in a statement (http://fpmpam.org/p_007.html) 2- See the PPS Column by the Malaysian Medical Association (MMA) in March, 2011 (http://www.mma.org.my/Portals/0/March-pps.pdf) 3- See the slides presentation on Investments in Healthcare – Insurance Implications by Frost & Sullivan in June 2010
104
6.1.1 Minimal fees paid to medical professionals
The biggest effects of weak regulation over MCO is the fee structure imposed by MCOs
to medical professionals especially private panel clinic doctors. Consultation and
medication fees are capped at RM30 although medical providers are eligible to charge
more based on the Seventh Fee Schedule of the Private Healthcare Facilities and
Services Act 1998, which is the fee structure established for private clinic. A newspaper
report indicated that an average allowable consultation fee paid by MCOs to Registered
Medical Practitioners (RMPs) in private clinics is only RM15, which is 50% less than the
maximum consultation fee in schedule Seventh. The same report further stated that
there are MCOs which impose a service fee of 10% from each patient’s treatment
charged by RMPs7.
Box 6.1 : Private Healthcare Facilities and Services (Private Medical Clinics or Private Dental Clinics) Regulation 2006
Seventh Schedule A. Consultation Fees 1. General Practitioners (Non specialists) (a) Clinic with pharmaceutical services
Item Fee (RM)
Consultation only
10 - 35 Consultation with examination
Consultation with examination and treatment plan
Consultation after stipulated clinic hours Up to 50% above the usual rate
House call or home visit Up to 100% above the usual rate
b) Clinic without pharmaceutical services
Item Fee (RM)
Consultation only
30 - 65 Consultation with examination
Consultation with examination and treatment plan
Consultation after stipulated clinic hours Up to 50% above the usual rate
House call or home visit Up to 100% above the usual rate
2) Specialist Fees a) First Visit/ Initial Consultation
Item Fee (RM)
Consultation only
60 - 180 Consultation with examination
Consultation with examination and treatment plan
7 Utusan Malaysia, 22 September 2015
105
Consultation after stipulated clinic hours Up to 50% above the usual rate
House call or home visit Up to 100% above the usual rate
b) Follow-up visit/follow-up consultation
Item Fee (RM)
Consultation only
35 - 90 Consultation with examination
Consultation with examination and treatment plan
Consultation after stipulated clinic hours Up to 50% above the usual rate
House call or home visit Up to 100% above the usual rate
Despite the issue faces by private clinics operator, there is no evidence of minimum fee structure
imposed upon private hospital panel doctors and specialists. For the record, private hospital fee
are regulated by Thirteenth Schedule of the PHFSA 1998. The schedule as below:
Box 6.2: Private Healthcare Facilities and Services (Private Hospitals and Other Private
Healthcare Facilities) (Amendment) Order 2013
Thirteenth Schedule
A. Consultation Fees
1. General Practitioners (Non specialists)
(a) First Visit /Initial consultation
Item Fee (RM)
Consultation only
30 - 125 Consultation with examination
Consultation with examination and treatment plan
Consultation after stipulated clinic hours Up to 50% above the usual rate
House call or home visit Up to 100% above the usual rate
b) Clinic without pharmaceutical services
Item Fee (RM)
Consultation only
35 - 145 Consultation with examination
Consultation with examination and treatment
plan
Consultation after stipulated clinic hours Up to 50% above the usual rate
House call or home visit Up to 100% above the usual rate
106
2) Specialist Fees
a) First Visit/ Initial Consultation
Item Fee (RM)
Consultation only
80 - 235 Consultation with examination
Consultation with examination and
treatment plan
Consultation after stipulated clinic hours Up to 50% above the usual rate
House call or home visit Up to 100% above the usual rate
b) Follow-up visit/follow-up consultation
Item Fee (RM)
Consultation only
40 - 105 Consultation with examination
Consultation with examination and
treatment plan
Consultation after stipulated clinic hours Up to 50% above the usual rate
House call or home visit Up to 100% above the usual rate
As seen in both schedules there is big difference between the allowable fees for
RMP in clinics compares to RMP in private hospitals. Interview with CKPAS of the MOH
on 26 April 2016, revealed that the difference occur because of Seventh fee schedule
was not revised when Schedule Thirteenth was revised in 2013. Medical professionals
have raised that the current Seventh fee schedule is too low and does not meet the
industry standard. The fact of the matter is that doctors’ professional fees are capped
and this has only been increased by 14.4% since the year 2000 working out to be a
mere 1% per annum. RMPs have been quietly absorbing the yearly increase in cost of
running a clinic8.
Over the years, the situation is worsened as the number of cash paying patient
decreases as almost 15 million or 50% of Malaysian population become insurance
8 Federation of Private Medical Practitioner’s Associations, Malaysia (FPMPAM) (2014) Message from President: Doctors’ Fees and Fee-Splitting, Suara FPMPAM, see: http://fpmpam.org/newsletter/SUARA_FPMPAM_Issue%201_2014.pdf
107
policy subscribers9. Whilst over 1 million others are private sector employees covered
under the TPA facility. In order for RMPs to obtain patient flow and sustain their clinic
set ups, they have to enter into agreement with MCO. However, this leads to MCOs
high bargaining power and results in low fee structure imposes upon the RMPs which
is between RM10 - RM15. Based on Seventh Schedule, the MCOs have not violated
the Act. However, the fee is far too low compared to the maximum of RM35 and RM65
allowable as consultation fees (refer to Box 6.1).
The low fee structure imposes upon the RMPs by the MCOs could be driven by the
promise to provide a more efficient medical fees management and reduced cost to their
clients (payors). Despite the positive intention, study and interviews with owners of
panel clinics disclosed that this is done at the expense of the RMPs, which has led to
inefficient patient’s services including the practice of treatment unbundling, prescription
of generic / low cost medicine and prescription of medicine in reduced quantity which in
the end would discriminate the patient’s rights to the most fitting medical services.
The ripple effect of MCO’s cost cutting measure could be the nonconformity of Section
12 of the Consumer Act 1999, as recorded in Box 6.3. Nevertheless, despite the cost
cutting promised by the MCOs as the value proposition of their service, there has been
no study conducted on the actual savings by businesses after the existence of MCO.
9 Star Online, Tan Kay How (2014) ,Malaysian Grossly Underinsured, see : http://www.thestar.com.my/news/community/2014/12/05/msians-grossly-underinsured-only-half-of-population-have-some-form-of-life-insurance/
108
2) Consumer Protection Act 1999
Box 6.3: Under the Consumer Protection Act 1999
Section 12 : Misleading indication as to price
(1) A person commits an offence –
(a) if he gives to a consumer an indication which is misleading as to the price at
which any goods or services are available; or
(b) if an indication given by him to a consumer as to the price at which any
goods or services are available becomes misleading and he fails to take
reasonable steps to prevent the consumer from relying on the indication
Looking at this issue, it is believed that there is an opportunity for the revision of the fee
Schedules and regulation over MCOs’ practice. The fee schedule could be revised by
increasing the minimum fee and reducing the range between minimum and the ceiling
fee. Such a revision could provide a more competitive fee for RMPs. This could help the
RMPs to better manage their clinical operations as well as reduce/eliminate the practice
of treatment unbundling, prescription of generic / low cost medicine and prescription of
medicine in reduced quantity.
6.1.2 Delayed and partial reimbursement
On top of the minimum pay structure, MCOs have also reportedly delayed payment
reimbursement to panel hospitals and clinics. On average, a report has cited that this
delay has ranged from 90 days to 365 days from the date of invoice from RMP. In
addition to that, payments are also made partially (piecemeal) not as per total invoice
amount. A report has cited that MCO being a third party administrator for healthcare
currently owes 35 doctors in Malaysia an amount of over RM1,000,000 for the medical
services rendered to patients registered under their medical panel. Interviews with
medical professionals further confirms this and unpublished report also stated that the
amount due may have reached a few millions. RMPs are also exposed to the risk of
non-payment as there have been cases where MCOs revoked their operations or
involved in merger and acquisition process without transferring their liabilities (money
owed to RMPs) to the new establishments. For the record the number of MCOs has
reduced from 49 in 2000 to 29 in 2016, source by MOH information.
109
Under the Private Healthcare Facilities & Services Act 1998 (Part XV: Managed Care
Organisation), Section 82 to 86 do not mention MCO’s responsibilities with regards to
their financial commitments, obligations and reimbursement timeframe to their panels.
The only indication to this commitment is mentioned in the Guidelines for Managed Care
Organisations and Private Healthcare Facilities and Services (2013) (sections 5.1(vii)
and 6.11) where both the RMPs and MCOs are eligible to establish a grievance
mechanism plan and grievance procedure for addressing any grievance on monetary
arrangement or payment or reimbursement of professional or healthcare facility or
services’ charges in the contract or arrangement. However, the guideline has no legal
influence on the subject as discussed above.
Current practice indicates that the MCO guidelines has not been implemented
effectively by the industry players, nor has it been regulated efficiently by the Regulators
concerned. RMPs are still operating under the domineering administrative structure of
MCOs especially on fee and reimbursement. RMPs find it challenging to negotiate on
new terms with MCOs due to MCOs position within the healthcare industry where a
large number of patients (estimated at 16.36 million in 2014)10 are the enrollees of
MCOs. This indicates that the MCO controls a large market share of patients in a
monopoly structure. The event suggests that the MCOs have an unjust position of
market monopoly that is significantly preventing, restricting and distorting competition
for goods or services, as stated in Chapter 1 of the Competition Act 2010 illustrated in
Box 6.4.
10 Calculated based on article from Star Online, Tan Kay How (2014) ,Malaysian Grossly Underinsured, see : http://www.thestar.com.my/news/community/2014/12/05/msians-grossly-underinsured-only-half-of-population-have-some-form-of-life-insurance/ (50% of total population) and Daniel Simonet (2009), Managed Care Expansion to Asia :A Critical Review (10% of subsribers from private company) MCO enrollees : 10% from total EPF subsribers + total population
110
Box 6.4 : Competition Act 2010
Chapter 1: Anti-competitive agreement
4. Prohibited horizontal and vertical agreement
(1) A horizontal or vertical agreement between enterprises is prohibited insofar as the
agreement has the object or effect of significantly preventing, restricting or distorting
competition in any market for goods or services.
Chapter 2: Abuse of dominant position
10. Abuse of dominant position is prohibited
(1) An enterprise is prohibited from engaging, whether independently or collectively,
in any conduct which amounts to an abuse of a dominant position in any market for
goods or services.
The position enables the MCOs to impose biased terms on the RMPs and leave the
RMP with a limited opportunity to negotiate. Many RMPs operating small clinics
highlighted that their protest against the low fee structure and reimbursement delay has
resulted in losing of a large market share of patients. This is an indication of a
noncompliance to Clause 6.2 of MCO guideline where all MCOs shall not remove any
RMP from the “cashless” benefits without establishing and adhering to an orderly and
adequate procedure that is applicable uniformly in all cases which shall include reminder
and opportunity for his defence.
6.1.3 Intervention on clinics operation
MCOs have also reportedly tried to intervene into patients’ confidential information,
determining the type of medicines and degree of treatment to patients. It is doubtful that
this practice would provide adequate service for patients. That is because MCOs usually
hire nurses and medical assistant to make final decision regarding patient’s treatment.
In this case, the public who expects that an RMP will provide and maintain a good
standard of medical care maybe misled by decision made often remotely by the MCO
representatives. This could lead to a breach of Section 83 of PHFSA (Contracts
between Private Healthcare Facility or Service and managed care organization). The
section specifically stated that:-
111
(1) The licensee of a private healthcare facility or service or the holder of a certificate of
registration shall not enter into a contract or make any arrangement with any managed
care organization that results in -
(a) a change in the powers of the registered medical practitioner or dental
practitioner over the medical or dental management of patients as vested in
paragraph 78(a), and a change in the powers of the registered medical practitioner
or visiting registered medical practitioner over the medical care management of
patients as vested in paragraphs 79(a) and 80(a);
(d) the contravention of the code of ethics of any professional regulatory body of the
medical, dental, nursing or midwifery profession or any other healthcare
professional regulatory body; as shown below:-
Box 6.5: Code of Professionals Conduct
1.1. Responsibility for Standards of Medical Care to Patients
In pursuance of its primary duty to protect the public, the Council may institute
disciplinary proceedings when a practitioner appears seriously to have disregarded
or neglected his professional duties to his patients. The public is entitled to expect
that a registered medical practitioner will provide and maintain a good standard of
medical care. This includes:-
a. conscientious assessment of the history, symptoms and signs of a patient's
condition;
b. sufficiently thorough professional attention, examination and where necessary,
diagnostic investigation;
c. competent and considerate professional management;
d. appropriate and prompt action upon evidence suggesting the existence of
condition requiring urgent medical intervention; and
e. readiness, where the circumstances so warrant, to consult appropriate
professional colleagues
Similarly, such a breach is also prohibited under the Guidelines for Managed Care
Organisations and Private Healthcare Facilities and Services, as mentioned in clause
5.2 (d): RMP shall:
112
(i) not participate in schemes that encourage or require him to practice below his
professional standards or beyond his competence;
(vi) at all times, in any contract or arrangement with MCOs, comply with the MMC’s
Code of Professional Conduct, its guidelines “Good Medical Practice” and
“Confidentiality” and other directives or guidelines issued out by MMC.
6.1.4 Selective Empaneling and Fee Splitting
The monopoly position of MCO also enables them to practice selective empanelling of
hospitals and clinics. This possesses the following effects:
(1) may limit the access of enrollees or policy holders to seek treatment from
preferred or more reputable RMPs and
(2) fee-splitting11
In Malaysia, it is estimated that over 16.36 million (2014) or 50% population are covered
under MCOs operations. 10% of this is private sector employees who are under the
TPA and the remaining 90% or 14.7 million are personal insurance policy subscribers12.
These enrollees or policy holders are eligible to seek treatment from private clinics and
hospitals under their panel listing. However, this does not reflect real access to medical
treatment as some MCOs may have limitations in term of number of panel clinics,
geographical location and expertise of RMPs. The situation causes burdens to RMPs
as they can only refer patients to panel specialist under the same MCOs. This also leads
to a noncompliance of Clause 6.7 of MCO guidelines which stated that all MCOs shall
not, at all times, interfere with the management of any patient by the RMP which include
the rights to refer a patient to any other suitable RMP to assist in the provision of
healthcare to the patient.
Preferred referral also encourages the act of fee-splitting (the payment of a commission
for referral or co-management of a patient). Fee splitting occurs where there is an
11 The practice of sharing fees with professional colleagues in return for referrals. It also involves the arrangement by a doctor or a group of doctors to co-manage a patient with another doctor or allied health professional, in return for some financial gain, which is not paid directly by the patient as a professional fee. 12 based on 50% of total population in 2014
113
agreement between an MCO with the payer which result in a capped fees structure
imposed by MCO to medical practitioners or panel clinics/hospitals. In return, these
panels gain an upper hand over patients care. For TPA, patients who are the employees
of the payers are only allowed to seek treatment from the panel clinics. Similarly, the
said medical practitioners can only refer patients for extended care to the TPA’s panel
hospitals, indicating a possible breach of Section 3.2.2. Dishonesty: Improper Financial
Transactions of the Code of Professional Conduct which stated that fee splitting is
prohibited if it compromises the quality of healthcare. In particular a Registered Medical
Practitioner (RMP) shall not engage in any fee-splitting or kick back arrangement when
referring patients to another colleague. This is also reiterated in the Guidelines for
Managed Care Organisations and Private Healthcare Facilities and Services Act
199813, Section 5.2 (a), stated that irrespective of whichever health care delivery
system a RMP practises in, he shall always place the best interests of the patients first.
Feedbacks gathered during interviews with medical professionals, particularly owners
of private clinics revealed that attempt to defy such practice has resulted in the removal
of a number of clinics from TPA’s panels, thus affecting their revenues. To date almost
2 million private sector employees are registered under TPA 14. To protect their market
share, panel clinics resume to adherence to TPA’s terms whilst, exposing patients to
the rippling effect of compromised healthcare.
Dr. Milton Lum in his article published by the Star in 2008, reported that there is an issue
of discounts given by hospitals to MCOs due to the volume of patients’ referrals.
Healthcare is being treated as a commodity where discounts are given when bulk
purchases of goods are made. Such principle is against the Code of Professional
Conduct and may subject the practitioner to disciplinary punishment under the Medical
Act 1971. This is supported by a statement from the then Director General of Health
that any form of discount on professional fees can be construed as intention to induce
that doctor to compromise his professional judgement for financial gain much to the
detriment of his patient 15.
13 Guidelines for Managed Care Organisations and Private Healthcare Facilities and Services (2013) 14 Daniel Simonet (2009), Managed Care Expansion to Asia :A Critical Review 15 Dr. Milton Lum (18 May 2008) Hospital charges and fee splitting, The Star Online: Available at: http://www.thestar.com.my/story/?file=%2f2008%2f5%2f18%2fhealth%2f21269252&sec=health
114
Figure 6.1 summarizes the chain reaction driven by the weak regulatory framework
particularly with regard to the fee structure
Figure 6.3: Summary of the Chain Reaction Driven by Weak Regulatory
Framework
MCO
Impact
Doctors
i) Creates a conflict of interest
ii) Exposure to breaching the Code of Professional Conduct
iii) Breach of Guidelines for Managed Care Organisations and Private
Healthcare Facilities and Services
iii) Creates unfair competition
Patients
i) Higher medical costs (possibly , doctor will pass down the cost to Cash payer
patient)
ii) Affect patient welfare
Payer
i) Higher medical costs
ii) Exposure to unnecessary charge
Relevant Acts/Regulations/Guidelines/Codes
According to the doctor's Code of Professional Conduct (1986)
Section 1.1. Responsibility for Standards of Medical Care to Patients
a. conscientious assessment of the history, symptoms and signs of a patient's condition;
b. sufficiently through professional attention, examination and where necessary, diagnostic investigations;
c. Competent and considerate professional management;
d. Appropriate and prompt action upon evidence suggesting the existence of condition requiring urgent medical intervention
3.2.2. Dishonesty: Improper Financial Transactions
The Council also regards fee-splitting or any form of kick back arrangement as an inducement to refer a patient to another practitioner as unethical. The premise for
referral must be quality of care. Violation of this will be considered by the Council as infamous conduct in a professional respect.
Section 3.4 The Practitioner and Commercial Undertakings
The practitioner is the trustee for the patient and accordingly must avoid any situation in which there is a conflict of interest with the patient
According to the Guidelines for Managed Care Organisationa and Private Healthcare Facilities and Services (2013)
5.1 Licensee or holder of certificate of registration of priate healthcare facility or service
(b)A licensee or a holder of certificate of registration of a private healthcare facility or service shall ensure any monetary arrangement or payment or reimbursement of
professional or healthcare facility or services' charges in the contract or arrangment shall not -
(i) compromise professional healthcare; or
(ii) breach any professional code of ethics.
5.2. RMPs engaged or privileged to practice
(d) A RMP shall –
(iii) not engage in any fee-splitting or kick-back arrangement when referring patients to another colleague;
6.2. All MCOs shall not remove any RMP from the “cashless” benefits without establishing and adhering to an orderly and adequate procedure that is applicable uniformly in all cases which shall include reminder and opportunity for his defence.
6.3. All MCOs shall ensure that their actions shall not allow for or cause or compel any RMP to breach the MMC’s Code of Professional Conduct and other directives or
guidelines issued out by MMC.
6.7. All MCOs shall not, at all times, interfere with the management of any patient by the RMP which include the rights to refer a patient to any other suitable RMP
115
6.2 Objectives of MCOs
In summary, the objective of MCO includes:
1) Helping to control the escalating cost of healthcare for the consumer while
respecting the provider’s ultimate authority in the treatment of patient (USA MCO,
2015)
2) Delivering or giving healthcare to consumers through a third party healthcare
provider in accordance with the contract or arrangement between all parties
concerned; and administering healthcare services to employees or enrollees on
behalf of payers in accordance with contractual agreements between all parties
concerned (Section 82 in PHFSA, 1998)
116
6.3 Options to resolve the issues
1. Status quo
The situation remains the same without any changes to the Act or Regulation. If
this option is chosen, the RMP will continue to face the same issue resulting from
the weak enforcement and regulation over the operation of MCOs.
2. Revise Seventh Fee Schedule under the PHFSA (2006)
This has its significance because Schedule Seven has not been revised since its
establishment in 2006. Therefore, it is important that the fee matches the cost of
living in current years. However, it is not recommended that the regulator
increases the ceiling fee of RM35 for clinics for clinics with pharmaceutical
services and RM65 for clinic without pharmaceutical services. This option
recommends that the fee schedule be revised by increasing the minimum
consultation fee from RM10 for clinics with pharmaceutical services and RM30
for clinic without pharmaceutical services to a more appropriate amount. This will
then reduce the range between the minimum and the ceiling fee. Such a revision
could provide a more competitive fee for RMPs. This could help the RMPs to
better manage their clinical operations as well as reduce/eliminate the practice
of treatment unbundling, prescription of generic / low cost medicine and
prescription of medicine in reduced quantity. This option also promotes a fairer
fee structure for RMPs which can avoid them from transferring their current
financial burden to the cash-paying patients hence benefitting the general public.
117
Example:
Current Fee Proposed Fee
Clinics with
pharmaceutical
services
Consultation fee RM10 - RM35 RM22.5 - RM35
RM22.5 = minimum fee
calculated based on the
median of RM10 – RM35.
Range RM25 RM12.5
Clinics without
pharmaceutical
services
Consultation fee RM30 – RM65 RM47.5 – RM65
RM47.5 = minimum fee
calculated based on the
median of RM30 – RM65.
Range RM35 RM17.5
Based on the proposed fee revision of Schedule Seven, it is estimated that RMPs
will receive a minimum increase of 83% of consultation fee, which will help to
ease the financial burden faced by RMPs in clinical operation as well as improve
the fee structure imposed by MCOs upon RMPs.
The 48% increased of minimum consultation fee should make up to the 10 years
increment of approximately 5% per annum. This also coincide with the Aon
Hewitt’s new salary survey which stated that the salary increment for employees
in Malaysia is at 5.8% in 2016 – up from 5.6% in 201516. The survey supports the
viability of the option to revise the Seventh fee Schedule.
In addition to that, it is also suggested that a regulation be established to enable
RMPs to negotiate with MCOs over the fee structure based on their own practice
costs without exceeding the ceiling fee of the schedule. This include the cost of
running medical practices which varies across the country, includes employing
practice staff, RMPs years of experience and operating expenses such as
16 Aon Hewitt (2015) Aon Hewitt’s View on Transforming the HR Landscape, Latest Insights on Attracting, Rewarding and Retaining Talent in Malaysia’s Current Economic Situation, see: http://aon.mediaroom.com/Aon-Hewitt-s-View-on-Transforming-the-HR-Landsape
118
computers, rent, and electricity. This is as benchmarked against the Australian
Medical Association17.
3. Regulate MCO under the MCO Bill
MOH as a regulator should regulate the MCO’s practice in Malaysia by drafting
the MCO Bill. The new Bill should emphasize on the following areas:
i) All items stated in MCO Guideline so that the accountabilities of MCOs
are regulated (currently the guidelines does not have legal influence over
MCOs)
ii) The new fee schedule to ensure it is enforced effectively.
iii) Cover items on financial commitment by MCOs towards RMPs. This
includes the obligation by MCOs to reimburse all costs due to RMPs within
an agreed timeframe. MCOs should also be liable towards all liabilities as
stated in the Companies Act 1965 and Insurance Act 1996. Failure to
comply should subject MCOs to legal action as deemed fit by the law.
iv) Registered MCOs are accountable to hire certified primary care
practitioner (PCP), who will be responsible for coordinating subscribers’
health care18. PCP will then refer the patients to specialists or other health
care providers or procedures as necessary. This has been implemented
in other country such as the United States as an initiative to maintain the
quality of healthcare and management of patient through MCO.
v) Review of contracts between the MCO, health providers and subscribers.
This is to benchmark the practice of the Department of Health, New York
that requires the Division of Health Plan Contracting and Oversight
(DHPCO)19 to review and approve the HMO/MCO and IPA provider
contracts to ensure that applicable laws and regulations are adhered to
(for example, the fee schedules for medical professionals)
17 Australian Medical Association (2016) Fees Lists, see: http://ama.com.au/resources/fees-list 18 Department of Health (Feb 2016) Managed Care: Provider Contract Guidelines for MCOs and IPAs, see: https://www.health.ny.gov/health_care/managed_care/hmoipa/hmo_ipa.htm 19 Department of Health (Feb 2016) Managed Care: Provider Contract Guidelines for MCOs and IPAs, see: https://www.health.ny.gov/health_care/managed_care/hmoipa/hmo_ipa.htm
119
vi) The responsibilities of MCOs to ensure that the list of panel clinics is
revised annually based on quality of service, independence and patients’
feedback.
vii) MCOs to declare annual financial status, and risk of insolvency to the
Department. In the event where the MCOs are not able to fulfill the
reimbursement schedule with the healthcare providers, early declaration
to the both the Department and providers are also required, so that early
measures could take place.
viii) Introduce stringent penalty clauses that regulate the practice of MCO in
Malaysia
2. Promote Competition and allow Open Market - Third Party Administrator (Not
including Insurance Companies).
Promote open market whereby clinics could register as panel directly under
companies (payer). To ease the management of payment by payer to individual
clinics, each RMP and payer must employ an electronic system for claim and
payment. However, details on responsibility for system installation and cost
involved must be discussed between both parties involved.
This is relevant because:
The role of TPA in helping companies reduce medical cost has not been
proven with any official studies and statistics.
However, there are many weaknesses in the implementation of TPAs
practices against relevant Acts and Guidelines.
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6.4 Recommended Option
Based on the options discussed above, the research party would like to
recommend Option 2 and 3. Option 2 could provide a higher consultation fee for
RMPs which will ease the financial burden faced by RMPs in clinical operations.
This option also promotes a fairer fee structure for RMPs which can avoid them
from transferring their current financial burden to the cash-paying patients hence
benefitting the general public. The 48% increased of minimum consultation fee
should make up to the 10 years increment at approximately 5% per annum. This
also coincide with the Aon Hewitt’s new salary survey which stated that the salary
increment for employees in Malaysia is at 5.8% in 2016 – up from 5.6% in 201520.
This recommendation also provides flexibility as it enables RMPs to negotiate
with MCOs over the fee structure based on their own practice costs without
exceeding the ceiling fee of the schedule. This restriction will protect the public's
interest as the ceiling fee is capped at RM35 and RM65, the same amount as
when it was established in 2006.
Option 3 is essential because it provides legal weightage to the existing MCO
Guideline. This is important in establishing control over MCO’s operation as well
as providing a fair contractual binding between MCOs and RMPs, which will lead
to enhance protection for patients. The new bill would also include the obligation
by MCOs to reimburse all costs due to RMPs within an agreed timeframe thus
improving business cash flow. RMPs will also be protected against non-payment
by MCOs as stated in the Company Act 1965 which was established to provide
a mechanism to protect creditors and those found guilty of mismanagement are
punished and where appropriate deprived of their right through disqualification,
from being involved in the management of other companies21. In addition to that
the bill should also refer to the Insurance Act 1996 where it covers the whole
process of winding up until the responsibilities to fulfill all liabilities to policy
20 Aon Hewitt (2015) Aon Hewitt’s View on Transforming the HR Landscape, Latest Insights on Attracting, Rewarding and Retaining Talent in Malaysia’s Current Economic Situation, see: http://aon.mediaroom.com/Aon-Hewitt-s-View-on-Transforming-the-HR-Landsape 21 Aishah Bidin (2004), Liabilities of Directors under Malaysian Insolvency Laws and Recovery of Assets During Corporate Insolvency
121
owners and debtors which includes RMPs22. All these would help to protect both
RMPs and MCOs as well as providing a more effective MCO operations for the
country.
22 Insurance Act 1996, Section 112
122
Chapter 7: Personal Data Protection Act 2010 (PDPA)
1. Inadequate quality control of
private colleges providing health
sciences education
2. Supplies of clinical training for
housemen and nursing
graduates
2. Lack of Regulatory Framework for MCO Operation - Minimal fees paid to medical
professionals
- Intervention on clinics
operation
- Delayed and partial
reimbursement
- Selective Empanelling and Fee
Splitting
3. Discrepancies between Personal Data Protection Act 2010 and PHFSA 1998 - The Redundancy on
Confidentiality - Difficulties to gain access of
data of Information
Pre-Qualification
Exit / Termination
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7.0 Personal Data Protection
7.1 Discrepancies between Personal Data Protection Act 2010 and PHFSA
1998
a) The Redundancy on Confidentiality of Information
Personal Data Protection Act (PDPA) 2010 regulates the collection, recording, holding
or storing of personal data, and carrying out of any operation on personal data for
commercial transactions. The Act, however, does not restrain a party from processing
data if the processing is done legitimately, in accordance with its principles. The Act
does not apply to Federal and State Governments; non-commercial transactions;
personal, family and household affairs; credit reference agencies; personal data
processed outside of Malaysia (unless the data is intended to be further processed in
Malaysia).
The PDPA categorizes data as follows:-
1) Personal data: means any information in respect of commercial transactions,
which—
(a) is being processed wholly or partly by means of equipment operating
automatically in response to instructions given for that purpose;
(b) is recorded with the intention that it should wholly or partly be processed by
means of such equipment; or
(c) is recorded as part of a relevant filing system or with the intention that it
should form part of a relevant filing system,
that relates directly or indirectly to a data subject, who is identified or identifiable
from that information or from that and other information in the possession of a
data user, including any sensitive personal data and expression of opinion
about the data subject; but does not include any information that is processed
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for the purpose of a credit reporting business carried on by a credit reporting
agency under the Credit Reporting Agencies Act 2010;
2) Sensitive personal data: means any personal data consisting of information as
to the physical or mental health or condition of a data subject, his political
opinions, his religious beliefs or other beliefs of a similar nature, the
commission or alleged commission by him of any offence or any other personal
data as the Minister may determine by order published in the Gazette;
PDPA is seen by practitioners as an additional burden and redundant as it has
already been addressed under the Private Healthcare Facilities and Services Act
(PHFSA) 1998. In addition to PDPA, registered medical practitioners have to abide by
the Malaysia Medical Council (MMC) guidelines which are the code of professional
conduct and the confidentiality guidelines for medical practice. The medical
practitioners, especially those operating small clinics, are concerned that the need to
apply with to the PDPA will involve more documentation and application fees.
One of the redundancies between PDPA with PHFSA and The Confidentiality
Guidelines is the method used to safeguard the confidentiality of information. Box 7.1
highlights the data protection clauses that guide data user on how to secure
information of the data subject.
BOX 7.1 : The Redundancy on Confidentiality of Information
1) Private Healthcare Facility Services Act 1998
Section 115
(1) Every person employed, retained or appointed for the purpose of the
administration or enforcement of this Act shall preserve secrecy with respect to
all information that comes to his knowledge in the course of his duties and
shall not communicate any information to any other person
(a) to the extent that the information is to be made available to the public
under this Act;
125
(b) in connection with the administration or enforcement of this Act or any
proceedings under this Act;
(c) in connection with any matter relating to professional disciplinary
proceedings, to a body established under any law regulating a health
profession;
(d) to the person's counsel, upon the person's request where the information
relates to any healthcare service provided to him; or
(e) with the consent of the patient or legal guardian to whom the information
relates.
(2) Any person who contravenes subsection (1) commits an offence and shall be
liable on conviction to a fine not exceeding one thousand ringgit.
2) Personal Data Protection Act 2010
Section 9
A data user shall, when processing personal data, take practical steps to protect
the personal data from any loss, misuse, modification, unauthorized or
accidental access or disclosure, alteration or destruction
3) The Confidentiality Guidelines by MMC
Paragraphs 10
When a practitioner is responsible for personal information about patients, the
practitioner shall ensure that the information and any documentation about it
are effectively protected against improper disclosures at all times
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b) Difficulties to gain access of data
Consent is considered as a major factor of the PDPA 2010. The medical professionals
brought up their concern on the stringent data control in the PDPA where only the data
subject has access to his/her information or could give consent to other data user
requiring the information. This is as per Section 39 of the Act:
Personal Data Protection 2010
Section 39
Personal data of a data subject may be disclosed by a data user for any purpose other
than the purpose for which the personal data was to be disclosed at the time of its
collection or any other purpose directly related to that purpose, only under the
following circumstances:
(a) the data subject has given his consent to the disclosure
7.2 The objective of the Act
Through the enforcement of PDPA 2010 (Security Principle), the data user believed
that they have to change the way they handle customers’ personal data. Security
Principle in PDPA is considered as the most challenging principle in processing
personal data since the businesses have to take practical steps to protect the
personal data from any loss, misuse, modification, unauthorised or accidental access
or disclosure , alteration or destruction1. Despite of that, the implementation of PDPA
will increase the cost in protecting the data since businesses have to use effective
security measures and proper tools to protect the personal data from being disclosed
to an unauthorised party unwillingly2. The relevant information of the Act is illustrated
in Box 8.8 below.
1 See article from Taylor Wessing (May 2014) (http://www.taylorwessing.com/globaldatahub/article_malaysia_dp.html) 2 See the article in The Star Online (2 February, 2014) (http://www.thestar.com.my/News/Nation/2014/02/02/Businesses-in-the-dark-over-the-PDPA/)
127
Box 7.2 : Personal Data Protection Regulations 2013
7.3 Verification with Regulators
Based on the issues discussed, a verification session was conducted with regulators,
Personal Data Protection Department (PDP) team. It was made to understand that the
department has provided a robust and dynamic approach to the PDPA where
industries are consulted in the development of Code of Practice that meets the
customised requirements of individual industry. To date, four industries have
established their code of practice under the PDPA, namely Banking, Utility, Insurance
and Communication.
According to the regulator, PDPA can be designed to ease the process of data
protection for business owner despite the issues raised by Medical Professionals with
regards to unnecessary burdens cause by it. PDPA is an industry driven Act and it
promotes self-regulation that can be customised based on industry requirement as
stated under Section 23 of PDPA: Code of Practice. The PDPA also stated that the
data user shall develop and implement a security policy for the purpose as long as it
complies with the security standard set out from time to time by the Commissioner.
The PDPA emphasizes on the accountability of medical professionals over data
subject information, however, it does not dictate the process of storing
data/file/patients’ record as mentioned in Section 9 of PDPA: Security Principle. In
summary, the section stated that a data user shall, when processing personal data,
Part II : Personal Data Protection Principles Security policy 6. (1) The data user shall develop and implement a security policy for the purposes
of section 9 of the Act. (2) The data user shall ensure the security policy referred to in sub-regulation
(1) complies with the security standard set out from time to time by the Commissioner.
(3) The data user shall ensure that the security standard on the processing of personal data be compiled with by any data processor that carry out the processing of the personal data on behalf of the data user.
128
take practical steps to protect the personal data from any loss, misuse, modification,
unauthorized or accidental access or disclosure, alteration or destruction. The PDPA
addresses the limitation faced by industry player’s especially small clinics with limited
resources. Therefore, PDPA allows any form of unique treatment to data as long as
the information is safely maintained and the data processer provides sufficient
guarantees and security measures.
According to the PDP department, most private hospitals are keen to register with
PDPA and to date, over 3000 private hospitals have registered as data user and/or
processor. However, the number of small clinics registering with the PDPA remains
minimal. Most established private hospitals see PDPA as a good assurance of
protecting customer’s data thus strengthening the marketability of their services,
especially to international patients seeking medical treatment in Malaysia. The PDPA
is also relevant with the government’s initiative to double the revenue of medical
tourism from RM 688 million to over RM1 billion in 2020.
The Personal Data Protection Department however faces challenges in developing
the code of practice for healthcare industry. The meeting set on 12 December 2015
has been postponed to January 2016, delaying the process much further. The PDP
department believes that the PDPA is very much relevant to the healthcare industry
based on the high level of data sensitivity. They also believe that the code of practice
would ease the registration and PDPA implementation of over 8000 private clinics as
it provides guidelines that cater specifically to the industry’s environment.
Redundancy on disclosures of the information
The investigation revealed that there is a misunderstanding with regards to the
requirements of PDPA against the medical professionals Act and PHFSA and that the
issue of redundancy of protection of information is not valid. That is because, although
the Medical Act 1971 states the necessity to protect patient’s data, it however does
not outline detail aspects of personal data protection as recognised by international
129
industry players. The Medical Industry practitioner may design their own
methodology of data protection including storage and administration of patient’s data
to specific suitability of the industry players, including private hospitals and small
private clinics.
The customised guideline could be incorporated into the Code of Practice for the
Healthcare Industry of the PDPA, as established by the Banking, Utilities, Insurance
and Communication Industries. It could be designed to ease the way of doing
business, enhance patient’s confidence in clinics and private hospitals data
administration thus strengthening the marketability of practices. Therefore, the
Medical Industry players should adopt a far-sighted approach and act fast to initiate
the development of the Code of Practice under the PDPA.
The PDPA also helps to establish greater confidence to the international industry
players as the clauses weighs down the impact of non-conformance to the Act. The
PHFSA stated that any person who contravenes the Act (Section 115 (2)(1)) commits
an offence and shall be liable on conviction to a fine not exceeding one thousand
ringgit while under the PDPA a person who contravenes the Act (Section 40 (3)(1))
commits an offence and shall, on conviction, be liable to a fine not exceeding two
hundred thousand ringgit or to imprisonment for a term not exceeding two years or to
both. That provides bigger protection to data subject and the confidentiality of his/her
medical information.
The principles of data treatment and security are well covered under the PDPA as it
also conceals a bigger spectrum of the industry. On the other hand, the Medical Act
and PHFSA did not emphasize on such. The revised guidelines on Confidentiality
Guidelines published by the MMC on October 2011 meanwhile focuses only on the
liability of Doctors who are registered with MMC in protecting and sharing patient’s
information. It does not cover other employees or data processors who are not
registered with the MMC. Moreover the guideline which is tied to the Medical Act 1971
imposes only minimum penalty to non-compliance and may not pose as a good
measure to deter noncompliance.
130
Table 7.1 illustrates the Comparison on data protection clauses stated in the
Confidentiality Guidelines by the MMC, Private Healthcare Facilities and Services Act
1998 (PHFSA) and the Personal Data Protection Act 2010 (PDPA) :
Table 7.1: Comparison on data protection between Confidentiality Guidelines, Private
Healthcare Facilities and Services Act and PDPA Act.
Confidentiality Guidelines
- MMC
PHFSA
(Ministry of Health, MOH)
PDPA
(PDP Department)
Overall Guidelines
mention about how
doctors registered with
MMC are liable to data
protection
Clause stating all medical
practitioners registered
with MMC :
automatically refer to
doctors only
Data protection: electronic
etc.
Sharing patients’ info:
Consent, How to share,
with whom can share.
Section 115.
Confidentiality of
Information
(1) Every person
employed, retained or
appointed for the purpose
of the administration or
enforcement of this Act
shall preserve secrecy
with respect to all
information that comes to
his knowledge in the
course of his duties and
shall not communicate
any information to any
other person except -
(a) to the extent that the
information is to be made
available to the public
under this Act;
(b) in connection with the
administration or
Section 40. Processing
of sensitive personal
data
(1) Subject to subsection
(2) and section 5, a data
user shall not process any
sensitive personal data of
a data subject except in
accordance with the
following conditions:
(a) the data subject has
given his explicit
consent to the
processing of the
personal data;
(b) the processing is
necessary –
(iv) for medical purposes
and is undertaken by—
(A) a healthcare
professional; or (B) a
person who in the
131
Confidentiality Guidelines
- MMC
PHFSA
(Ministry of Health, MOH)
PDPA
(PDP Department)
enforcement of this Act or
any proceedings under
this Act;
(c) in connection with any
matter relating to
professional disciplinary
proceedings, to a body
established under any law
regulating a health
profession;
(d) to the person's
counsel, upon the
person's request where
the information relates to
any healthcare service
provided to him; or
(e) with the consent of
the patient or legal
guardian to whom the
information relates.
(2) Any person who
contravenes subsection
(1) commits an offence
and shall be liable on
conviction to a fine not
exceeding one thousand
ringgit.
circumstances owes a
duty of confidentiality
which is equivalent to that
which would arise if that
person were a healthcare
professional;
(3) A person who
contravenes subsection
(1) commits an offence
and shall, on conviction,
be liable to a fine not
exceeding two hundred
thousand ringgit or to
imprisonment for a term
not exceeding two years
or to both.
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In addition, the Act also governs the practice of third party data processor acting on
behalf of data user (medical professional) as stated in Section 9 of the Act “The data
user shall ensure that the security standard on the processing of personal data be
compiled with by any data processor that carry out the processing of the personal data
on behalf of the data user”. That provides better protection to data subject whist
increasing patients’ confidence to seek treatment in PDPA registered clinics and
hospitals. Such a clause however does not exist in the PHFSA nor the other existing
guidelines on the administration of patients’ data.
Restriction in Accessing Patient’s Data
The verification session with the regulator and further studies on the PDPA Act has
confirmed that there is an element of serious restriction where only data subject
could give consent to data release.
One medical practitioner shared that parents of a deceased child has not been given
the permission to access their child’s medical history record as there was no consent
given by the deceased, who died at the age of above 18. Data however could only
be released under the court order as stated in Section 39 of the Act. However, the
“Extend of Disclosure of Personal Data” but would involve lengthy legal processes
and high cost.
Box 7.3 : Personal Data Protection Regulations 2010
Section 39 : Extend of Disclosure of Personal Data
Notwithstanding section 8, personal data of a data subject may be disclosed by a
data user for any purpose other than the purpose for which the personal data was
to be disclosed at the time of its collection or any other purpose directly related to
that
purpose, only under the following circumstances:
(a) the data subject has given his consent to the disclosure;
(b) the disclosure —
133
(i) is necessary for the purpose of preventing or detecting a crime, or for the
purpose of investigations;
or
(ii) was required or authorized by or under any law or by the order of a court;
(c) the data user acted in the reasonable belief that he had in law the right to
disclose the personal data to the other person;
(d) the data user acted in the reasonable belief that he would have had the
consent of the data subject if the data subject had known of the disclosing of the
personal data and the circumstances of such disclosure; or
(e) the disclosure was justified as being in the public interest in circumstances as
determined by the Minister
This restrictions have caused a regulatory and administrative burden to medical
professionals as whether to comply to the PHFSA 1998 and Code of Professionals
Conduct, which provides better flexibility where the data user could request the
consent from the data subject or a person authorized to Act on the patient’s behalf
for any disclosure of information, or comply to the PDPA’s restriction.
The related clauses under the relevant Acts and guidelines are highlighted in Box
7.4.
BOX 7.4 : Disclosures of the information
1) Private Healthcare Facility Services Act 1998
Section 115, Subsection 1(e)
With the consent of the patient or legal guardian to whom the information relates.
2) The Confidentiality Guidelines
Paragraph 21
A practitioner may release confidential information in strict accordance with the
patient’s consent or the consent of a person authorized to act on the patient’s
behalf. Seeking patient’s consent to disclosure of information is part of good
medical practice.
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The Code of Professional Conduct 1986 however does not specify the role of any
authorised person to act on behalf of the data subject as stated in the Code of
Professionals Conduct Subsection 2, which stated that “A practitioner may not
improperly disclose information which he obtained in confidence from or about a
patient”. This gives flexibility to medical practitioners to obtain consent for patient’s
data release from the legal guardian or other authorised person. This is especially
relevant for patients under 18, as stated in Section 24 of the Child Act 2001 as
illustrated in Box 8.7.
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7.4 Options to resolve the issues
The following options are put forward to resolve the issues of redundancy in the PDPA
implementation:
1. Status quo
PDPA remains in action without any changes to the principles of the Act. That is
because there is no redundancy in the manner of protection data in the PDPA
against the PHFSA. The issue was raised mainly due to lack of understandings
by businesses on the purpose of the Act or what they are required to do.
2. Expedite the development/establishment of Code of Practice
o Benefit: PDPA that supports the industry
o Addresses concerns & limitations
o Managing business compliance costs across the board
3. Strengthen communication to establish better understanding of PDPA among
medical professionals. This must be done after the establishment of code of
practice.
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7.5 Recommended options
It is recommended that all options be implemented due to the followings:
Option 1: There is clearly no redundancy in the PDPA against the existing PHFSA Act.
The PDPA was developed to provide a holistic guideline to data protection involving
data subject, data user and data processor. However the PHFSA only addresses
specific areas of data protection which does not include the manner to process, secure
and store data. The PHFSA also does not mention of any liability of third party data
processor acting on behalf of data user. Hence, the PDPA does not contradict of pose
redundant to the PHFSA.
Option 2 is also recommended to complement Option 1. That is because the
development/establishment of Code of Practice would provide medical professionals
with a specific guideline on data protection that is customised to the Healthcare
Industry. The Code of Practice would address needs and limitations of medical
practitioners in processing, storing and securing patients’ data especially for those
operating small clinics. The Code of Practice will also provide every party (data
subject, data user, processor) a clear picture in determining the objective of secrecy
of the data. With this in mind, the appropriate policies and procedures regarding the
collection, processing, retention and disclosure of personal data can be implemented3.
To compliments options 1 and 2, the PDP Department is recommended to strengthen
communication with industry players, particularly medical practitioners operating small
clinics. Apart from communication, the Department could take a proactive role by
developing independent data processors who are able to process data in accordance
to the PDPA requirements. These trained data processors could support the
administrative data management function for small clinics based on outsourcing
services. This would ease the transition for small clinics into PDPA. This approach
has been successful based on the experience of the Custom Department in easing
the implementation of the Goods and Services Tax (GST) throughout 2014 to 2015.
3 See article form HG.org (http://www.hg.org/article.asp?id=33273)