This is a March 2011 MOH presentation about the role of Primary Healthcare in the 1Care reforms.

1. 1
1Care for 1Malaysia
Primary Health Care
SJ /10Mar 2011

2. 2
Benefits 1CARE
1. Achieving enhanced universal coverage
2. Integrating public and private sectors
3. Ensuring an affordable and sustainable health care system for
Malaysians
4. Providing equitable (in terms of access and financing), efficient, and
higher quality services; and better health outcomes for the Nation
5. Developing effective safety nets for the risk protection of vulnerable
groups
6. Remodelling the health system to become more responsive to
population needs
7. Enhancing client satisfaction
8. Promoting personalised and better managed care for the individual and
family
9. Reducing the brain-drain of skilled personnel both internally and
internationally
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3. 3
1. Achieving enhanced universal coverage
• Every member of the population is registered (looked after) by a
Primary Health Care Physician
• Urban and Rural
• All members of the population
2. Integrating public and private sectors
• GPs and FMS will be integrated as one Primary Health Care
Physician group
• In KKs public sector 1000 vs 3000 post
• 200 plus 7000 GPs
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4. 4
3. Ensuring an affordable and sustainable health
care system for Malaysians
• No payment at point of care
• Capitation : promotes preventive services and wellness and early
case management
4. Providing equitable (in terms of access and
financing), efficient, and higher quality services;
and better health outcomes for the Nation
• Capitation
• Benefit package from womb to tomb
• Pay for performance
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5. 5
5. Developing effective safety nets for the risk
protection of vulnerable groups
• All members of the population
▫ Rich covers the poor
▫ Healthy covers the sick
▫ Young covers elderly
6. Remodelling the health system to become more
responsive to population needs
• Health Package meeting needs of the population
• Covers all member of the population close to their home
• Providers of their choice
• Autonomous
• Risk sharing with providers
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6. 6
Core component
• Restructured health care • New financing mechanism
delivery • NHFA
▫ MHDS ▫ Capitation
▫ Autonomous ▫ SHI
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7. 7
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Figure 1: Functions Within the Restructured
1Care Health System
Independent bodies Professional Bodies
-Drug Regulatory Authority (DRA) -MMC
-MDC
-Health Technology As s es s ment (HTA)
-Pharm acy Board
-Medical Res earch Council (MRC)
- Others
-Patience Safety Council
-Medical Device Bureau
-National Service Fram ework (NSF)
(Quality)
-National Health Prom otion Board
NHFA
- Food Safety Authority
- Others MOH
• GOVERNANCE &
STEWARDSHIP
• POLICY & STRATEGY
FORMULATION
• STANDARD SETTING MHDS
• REGULATION &
ENFORCEMENT SERVICE DELIVERY
• MONITORING &
EVALUATION •PRIMARY CARE
• PUBLIC HEALTH
• RESEARCH •HOSPITAL CARE
• TRAINING
•OTHER SERVICES

8. 8
SHI
MOH NHFA PRIVATE
HKL & Special
PROVIDERS
Institutions
PRIVATE
STATE STATE HEALTH HOSPITALS
HOSPITALS DEPT State NHFA
NETWORK
PUBLIC PROVIDERS
DISTRICT DISTRICT PRIVATE PHCP
PHC Board
HOSPITALS HEALTH OFFICE (GPs)
HEALTH CLINICS
Funding flow NHFA – part of MOH
Governance

9. 9
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Patient Additional services
(Out of pocket or private health insurance)
PHCP Refer Private
Public Private Hospital
Public
Admit
Receive
treatment
Return to referring PHCP
Home

10. 10
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Specialized care Community Emergency Hospital
mental department
TB
health unit Maternity
control
centre Consultant Traffic
support
Referral for accident Placenta Surgery
Diabetes clinic multi-drug resistance praevia
Referral for Hernia
complications
Diagnostic services Self-help
Primary-care team:
Diagnostic support group
continuous,
CT Training Training
comprehensive,
Scan support centre
person-centred care
Liaison Social
Pap community
Cytology smears services
lab health worker Other
Other
Alcoholism
Waste disposal
Community Alcoholics
Gender
inspection violence anonymous
Mammography
Environmental
health lab Women’s NGOs
Cancer
shelter
screening
Specialized
centre
prevention services

11. 11
Primary Health Care Physician PHCP
• Doctors • Trained medical doctors from
• Solo or group accredited institutions
• Independent contractors • Registered with the MMC and
• Family doctor concept permitted to practice
• Gatekeepers • As specialist-National
• Every individual is registered Specialist Register
to PHCP/ratio/special groups
• Over time only Primary Health
Care Physicians are allowed to
open a PHCP practice.
• Secondary care specialist -not
be registered as PHCPs
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12. 12
REGISTRATION OF PHCP
Population : 90,600
Private Hosp. : 0, MOH Hosp. : 1
• Data base of both PHCP and population :
Population : 36,400
Private Hosp. : 0, MOH Hosp. : 1 Population : 96,600
Private Hosp. : 0, MOH Hosp. : 1
matching population density to supply
▫ Gatekeeper
▫ Training and accreditation mechanism
▫ Mechanism for payment, tracking and monitoring
▫ Mechanism for addressing disruption of services Population : 429,100
Population : 93,700
 Relocation Private Hosp. : 0, MOH Hosp. : 1
Private Hosp. : 3, MOH Hosp. : 1
Population : 135,700
 Vacation Population : 153,900
Private Hosp. : 0, MOH Hosp. : 1
Locum and substitute doctor
Private Hosp. : 0, MOH Hosp. : 1
 Population : 127,300
Private Hosp. : 0, MOH Hosp. : 1
▫ Arrangements for with group practices
Population : 116,800
Private Hosp. : 0, MOH Hosp. : 1
 Features to encourage group practices
• Patients
Population : 95,700
▫ reliable mechanism for registering without Population : 137,400
duplications Private Hosp. : 0, MOH Hosp. : 1
▫ register according to residence, work place / school
▫ changing provider
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13. 13
Distribution of primarycare doctors
WILAYAH PERSEKUTUAN KUALA LUMPUR & PUTRA
Bilangan klinik
Daerah Klinik Kerajaan yang ada Pegawai Klinik Swasta
Perubatan
Wilayah Persekutuan Kuala Lumpur 13 13 943
Wilayah Persekutuan Putrajaya 1 1 8
JUMLAH 14 14 951
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KEDAH
Bilangan klinik yang ada
Daerah Klinik Kerajaan Klinik Swasta
Pegawai Perubatan
Kota Setar 10 8 80
Kulim 9 6 38
Baling 5 4 6
Pendang 3 2 8
Bandar Bahru 3 2 0
Sik 2 1 3
Padang Terap 3 3 0
Yan 2 2 2
Kuala Muda 6 4 1
Kubang Pasu 8 5 1
Langkawi 3 2 11
JUMLAH 54 39 150
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SARAWAK
Bilangan klinik yang ada
Daerah Klinik Kerajaan Klinik Swasta
Pegawai Perubatan
Daerah Betong / Betong 9 0 2
Daerah Betong / Saratok 5 0 1
Daerah Bintulu / Bintulu 5 0 24
Daerah Bintulu / Tatau 4 0 -
Daerah Kapit / Kapit 10 1 1
Daerah Kapit / Belaga 6 0 -
Daerah Kapit / Song 5 1 -
Daerah Kuching / Kuching 13 3 136
Daerah Kuching / Bau 2 0 2
Daerah Kuching / Lundu 4 0 2
Daerah Limbang / Limbang 4 0 3
Daerah Limbang / Lawas 9 0 3
Daerah Miri / Marudi 21 0 1
Daerah Miri/Miri 8 3 42
Daerah Mukah / Dalat 2 0 -
Daerah Mukah/ Daro 8 0 -
Daerah Mukah/Matu 6 0 -
Daerah Mukah 9 0 3
Daerah Samarahan / Samarahan 6 0 6
Daerah Samarahan / Serian 8 0 3
Daerah Samarahan / Simunjang 6 0 -
Daerah Sarikei / Julau 6 1 8
Daerah Sarikei / Meradong 6 1 -
Daerah Sarikei / Pakan 4 0 -
Daerah Sarikei 2 1 -
Daerah Sibu / Kanawit 4 0 1
Daerah Sibu / Selangau 4 0 -
Daerah Sibu / Sibu 4 2 48
Daerah Sri Aman / Lubuk Antu 6 2 -
Daerah Sri Aman / Sri Aman 7 1 3
JUMLAH 193 16 289
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Benefit package for PHC
• Child health • Diagnostic Services
• Adolescent health • Radiological
• Women‟s health • Pharmacy
• Men‟s health • Pathology
• Family planning
• Antenatal care
• Postnatal care
• Elderly health
• Prevention /promotive
• Curative care
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17. 17
KKs will become Super PHCP Clinic
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Primary Health Care Physician
“scope of practice”
They are responsible for maintaining optimal health of their
„registered population‟ to provide “essential health package”
through:
• Screening and health assessment from of “womb to tomb”
• Health promotion and counseling /patient education
• Prevention activities (paps smear, immunization …)
• Diagnosis / differential diagnosis
• Intervention and treatment of common illness and medical
conditions
• Careplans , long-term care and follow-up
• Referral
• Data collection for patient and population analysis
• Participate in CPDs / CMEs
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Primary Health Care Physicians
“operations”
• Registers designated population
• Receives reimbursement based on per capita for the provision of
essential services
• Collects patients data and submit data and information as required
• Compliance to all standards and guidelines as well as service targets
• Commission secondary care from hospitals for patients where
relevant (at what rate?)
• Other services may include :
▫ Emergency services and Call Centres
▫ School health Services
▫ Rehab Services
▫ Flying Doctors Services
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20. 20
FUNDING & INCENTIVES
•Funding through capitation
•Case-mix methodology will be employed
• Additional Incentives will be provided for:
• Specialist qualifications
• House calls
• Additional payments for exceeding stipulated performance of
benchmarks
• Funding training and topping up courses
• Those working in rural or unpopular locations
• Those who treat more chronic patients
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CO-PAYMENT ?
• Co-payments will be nominal
• To address abuse / moral hazard and to promote
responsible use of services
• Likely services are for medicine and dental services.
• Need to identify range and scope of services like
duration, type and entitlement
• Very sensitive issue and require strong social advocacy
• Mechanism for waiver for those who cannot afford and
those with entitlement
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Benefits to the Benefits to the Benefits to the
Nation people Providers
• Strengthen national unity • More access to providers • Bridge gaps remuneration and
• Stimulate the health care • Care nearer to home workload
market • No payment at point of • Optimize HR both sectors
• Reduces unnecessary seeking care (during hardship) • Encourage serving in rural
dependence on • Vulnerable group better areas
protected
government fund
• Quality care
• Appropriate level of
• Financial safety nets for
• Client satisfaction
competency and standard of
lower and middle income care
groups • Greater health outcomes for
community
• Contain the rapid growth
in health care cost and
inflation
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Next agenda
• Develop full blueprint within 2y
▫ Building blocks
 Mapping of population & providers
 Professional & care standards
 Benefit packages
 Monitoring & Evaluation
• Phased implementation, evaluation and monitoring
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TOR TWG PHC
1. Study the existing service provision and
perform mapping of gaps
2. Develop draft framework for PHC delivery
3. Develop phases for implementation
▫ awareness and motivation / buy-ins
▫ essential universal package
▫ standards, accreditation, credentialing and
privileging
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25. 25
TOR TWG PHC
Develop phases for implementation (cont’d)
▫ Health informatics
 Registration of providers and population
▫ Registration list of Primary Care Providers to the
Population
▫ Propose Organisational and Management Structure of
the various levels
▫ Develop clear roles and relationship of Primary Care
related NGOs & other Organizational Support
Systems
▫ Develop indicators to monitor risks or impact
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26. 26
TOR TWG PHC
4. Perform risk mitigation for each phase
▫ Identify, characterize, and assess threats (political and resources)
▫ Assess the vulnerability of critical implications to specific threats
(scope too big or too small, cost too high etc)
▫ Determine the risk (i.e. The expected consequences of specific
types of attacks on specific assets)
▫ Identify ways to reduce those risks
▫ Prioritize risk reduction measures based on a strategy
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1Care for 1Malaysia
mandate:
PHC :
Equity, Universality, Solidarity
SJ /10Mar 2011