TABLE 9.2d: OOP Health Expenditure to Providers of Health Care, 2011-2022 (Percent, %) Provider Name 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Private hospitals 46.74 44.38 41.17 39.25 41.60 42.22 43.61 43.26 45.10 45.32 46.32 46.62 Private medical clinics 19.82 20.98 21.93 24.50 19.80 18.84 19.49 18.83 20.05 19.76 19.37 20.40 Private pharmacies 12.27 12.49 13.22 15.35 16.06 15.66 14.97 17.53 14.71 14.98 16.02 15.65 Private dental clinics 4.44 4.43 4.25 4.20 5.20 5.20 5.21 5.10 5.15 4.84 4.89 4.82 Traditional and Complementary Medicine (TCM) providers 3.43 3.25 3.04 2.94 3.27 3.55 3.37 3.13 2.98 2.77 2.78 2.71 Retail sale and other suppliers of medical goods and appliances 2.80 2.57 2.34 2.17 2.59 2.98 2.88 2.71 2.63 2.44 2.44 2.37 Private medical and diagnostic laboratories 0.38 0.47 0.56 0.70 0.44 0.19 0.18 0.16 0.16 0.14 0.14 0.14 All other private sector providers of health care 4.65 5.96 6.23 4.41 4.40 4.40 4.03 3.89 4.05 3.97 3.89 3.38 Sub-Total (Private Providers) 94.52 94.53 92.73 93.53 93.36 93.04 93.74 94.61 94.82 94.22 95.85 96.09 Public hospitals 2.26 2.00 2.40 2.01 2.19 2.53 2.25 2.02 2.05 2.27 1.92 1.77 Public medical clinics 0.40 0.40 0.32 0.31 0.29 0.27 0.22 0.20 0.20 0.30 0.16 0.12 Public institutions providing health- related services 2.83 3.07 4.55 4.15 4.09 4.08 3.71 3.09 2.84 3.15 2.00 1.95 Public dental clinics na na na na 0.08 0.08 0.08 0.08 0.09 0.05 0.06 0.06 Provision and administration of public health programmes (MOH) na na na na na na na na na 0.02 0.01 na Sub-Total (Public Providers) 5.48 5.47 7.27 6.47 6.64 6.96 6.26 5.39 5.18 5.78 4.15 3.91 Total 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 83 MALAYSIA NATIONAL HEALTH ACCOUNTS HEALTH EXPENDITURE REPORT 2011-2022
9.3 O U T - O F - P O C K E T H E A L T H EXPENDITURE FOR FUNCTIONS OF HEALTH CARE The data under this section responds to the question on the type of health care services and products that are purchased with the OOP spending. This includes expenditures for core functions of health care such as services of curative care, ancillary services, medical goods and appliances and others, as well as health- related functions such as capital asset purchases, education and training, research and development and others. In 2022 the largest proportion of OOP health expenditure was RM12,364 million (42.1% of OOP Health expenditure) for out-patient care services. This includes out-patient care services provided both in standalone medical clinics and hospital facilities. In the same year, in-patient care services were at RM7,158 million (24.4% of OOP health expenditure). This includes spending at public and private hospitals, with a greater proportion at private hospitals. The OOP health spending for pharmaceuticals, including over-the-counter and prescription drugs, was RM4,599 million (15.7% of OOP health expenditure), health education and training was RM1,498 million (5.1%), medical appliances and non-durable goods was RM985 million (3.4% of OOP health expenditure), day-care services at RM737 million (2.5% of OOP health expenditure), TCM was RM601 million (2.0% of OOP health expenditure), and the remaining RM1,439 million (4.9% of OOP health expenditure) was for other functions (Table 9.3a, Table 9.3b and Figure 9.3a). Although the 2011-2022 time series data shows a general increase in OOP health spending for various functions, the proportions showed some variations. Over these 12 years, the OOP health spending for out-patient services increased from RM5,145 million in 2011 to RM12,364 million in 2022. There is also a rise in spending on in- patient services from RM2,786 million in 2011 to RM7,158 million in 2022, with the proportion of this function fluctuating from 19.9% to 24.4% over the same period (Table 9.3b). There is a 3-fold increase in OOP health spending for pharmaceuticals from RM1,407 million in 2011 to RM4,599 million in 2022 and health education and training from RM789 million in 2011 to RM1,498 million in 2022 and almost a 2-fold increase in OOP health expenditure (Table 9.3a and Table 9.3b). 84 MALAYSIA NATIONAL HEALTH ACCOUNTS HEALTH EXPENDITURE REPORT 2011-2022
TABLE 9.3a: OOP Health Expenditure for Functions of Health Care, 2011-2022 (RM Million) Function Name 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Out-patient services 5,145 5,709 6,206 7,067 6,922 7,171 8,137 8,621 9,406 9,269 10,177 12,364 In-patient services 2,786 2,831 2,976 3,056 3,454 3,866 4,458 4,484 4,897 5,181 5,846 7,158 Pharmaceuticals 1,407 1,580 1,842 2,360 2,625 2,749 2,922 3,734 3,292 3,392 3,955 4,599 Health education and training 789 1,066 1,424 1,244 1,325 1,427 1,452 1,451 1,491 1,558 1,368 1,498 Medical appliances and non-durable goods 384 394 398 413 599 712 771 801 824 776 849 985 Day-care services 328 338 374 409 471 495 593 641 557 518 591 737 Traditional and Complementary Medicine (TCM) 298 310 317 335 407 489 513 513 507 476 519 601 All other functions 329 421 396 489 545 647 672 1,057 1,407 1,479 1,383 1,439 Total 11,466 12,649 13,933 15,373 16,349 17,555 19,518 21,302 22,382 22,648 24,688 29,381 TABLE 9.3b: OOP Health Expenditure for Functions of Health Care, 2011-2022 (Percent, %) Function Name 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 Out-patient services 44.87 45.13 44.54 45.97 42.34 40.85 41.69 40.47 42.03 40.93 41.22 42.08 In-patient services 24.29 22.38 21.36 19.88 21.13 22.02 22.84 21.05 21.88 22.88 23.68 24.36 Pharmaceuticals 12.27 12.49 13.22 15.35 16.06 15.66 14.97 17.53 14.71 14.98 16.02 15.65 Health education and training 6.89 8.43 10.22 8.09 8.10 8.13 7.44 6.81 6.66 6.88 5.54 5.10 Medical appliances and non-durable goods 3.35 3.12 2.86 2.69 3.67 4.05 3.95 3.76 3.68 3.43 3.44 3.35 Day-care services 2.86 2.68 2.69 2.66 2.88 2.82 3.04 3.01 2.49 2.29 2.39 2.51 Traditional and Complementary Medicine (TCM) 2.60 2.45 2.27 2.18 2.49 2.79 2.63 2.41 2.26 2.10 2.10 2.04 All other functions 2.87 3.33 2.84 3.18 3.34 3.68 3.44 4.96 6.29 6.53 5.60 4.90 Total 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 100.00 85 MALAYSIA NATIONAL HEALTH ACCOUNTS HEALTH EXPENDITURE REPORT 2011-2022
FIGURE 9.3a: OOP Health Expenditure for Functions of Health Care, 2022 86 MALAYSIA NATIONAL HEALTH ACCOUNTS HEALTH EXPENDITURE REPORT 2011-2022
FIGURE 9.3b: OOP Health Expenditure for Functional Proportion, 2011 & 2022 44.9% 42.1% 24.3% 24.4% 12.3% 15.7% 6.9% 5.1% 3.4% 3.4% 2.9% 2.5% 2.6% 2.0% 2.9% 4.9% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2011 2022 All other functions Traditional and Complementary Medicine (TCM) Day-care services Medical appliances & non- durable goods Health education & training Pharmaceuticals In-patient servi ces Out-patient services 87 MALAYSIA NATIONAL HEALTH ACCOUNTS HEALTH EXPENDITURE REPORT 2011-2022 PRIMARY HEALTH CARE (PHC) EXPENDITURE 10.1 CONCEPTUALIZATION OF PRIMARY HEALTH CARE T he concept of Primary Health Care (PHC) has evolved over the years since its original definition in the 1978 Declaration of Alma- Ata. Different interpretations of PHC exist, ranging from basic health care services to priority interventions for underserved populations. However, these interpretations often oversimplify the comprehensive approach outlined in the Alma- Ata Declaration, risking the loss of the benefits of a holistic PHC strategy. A comprehensive approach to health encompasses the whole government and whole of society approach, intending to achieve the highest level of health and well-being for all individuals and ensure equal access to healthcare services. The concept of PHC consists of three key components: · Integrated health services
This includes providing comprehensive care that addresses people’s health needs throughout their lives, focusing on promotion, protection, prevention, treatment, and palliative care. Additionally, it involves strategically prioritizing essential healthcare services for individuals, families, and the population. · Multisectoral policy and action
It involves addressing the broader determinants of health. This includes considering social, economic, and environmental factors, as well as individual characteristics and behaviours. Evidence-based policies and actions are implemented across all sectors to improve health outcomes. · Empowerment of individuals and communities
Recognizing their active role in promoting and maintaining their health is crucial. This involves providing individuals and communities with the knowledge, resources, and support necessary to make informed decisions about their health and actively participate in healthcare processes. 10.2 VARIOUS INTERNATIONAL PRIMARY HEALTH CARE GUIDELINES PHC is widely acknowledged as the cornerstone of any health system and is considered the most efficient, effective, and fair method of delivering essential health services to the majority of the population at the lowest possible cost. The recent updates from WHO, the Organisation for Economic Co-operation and Development (OECD), and The Lancet Global Health Commission have led to the development of various guidelines regarding the boundaries of PHC. • The OECD defines PHC expenditure as the spending on basic healthcare services derived from the healthcare function classification. This includes general outpatient curative CHAPTER 10 88 MALAYSIA NATIONAL HEALTH ACCOUNTS HEALTH EXPENDITURE REPORT 2011-2022
care, outpatient dental care, home-based curative care, and preventive care. An extended option also includes spending on pharmaceuticals. The expenditure is limited to services provided by ambulatory care providers. · On the other hand, the WHO’s definition of PHC also uses the health care function classification but includes additional components. These components are curative outpatient care not elsewhere classified, outpatient and home-based long- term health care, 80% of medical goods provided outside health care services, and 80% of health system administration and governance expenditure. The inclusion of hospital-based general outpatient care, pharmaceuticals, and administrative costs makes the WHO definition broader than the OECD’s definition. · The Lancet Global Health Commission uses the WHO’s definition of PHC expenditure but excludes administration and governance expenditures. This decision was made to provide a more focused analysis. TABLE 10.1 displays a summary of the different boundaries mentioned, compared to the old PHC boundaries of Malaysia. Globally, determining whether the amount spent on PHC Expenditure in a particular country is sufficient remains a challenge. Ultimately, the significance of expenditure lies in understanding how it is financed, the structure of the health system, fiscal conditions, and other relevant factors. It is crucial to recognize that monitoring PHC spending is not an end goal in itself, and the aim should not be solely to increase spending by a certain percentage. 10.3 MALAYSIA’S NEW BOUNDARIES OF PRIMARY HEALTH CARE The definition and scope of primary healthcare (PHC) may vary depending on the specific policy requirements of each country. In the past, a set of criteria was established in 2018 to define the boundaries of primary healthcare (PHC). However, as time goes on, it becomes necessary to adjust the country’s PHC boundaries to a new set that better reflects the current situation. TABLE 10.1: Comparison of PHC boundaries (Global) Description OLD MOH OECD WHO LANCET Provider Perspective YES YES NO NO Medical Goods NO YES, partial Extended Classification YES (80%) YES (80%) Governance, Health System, and Financing Administration NO NO YES (80%) NO Prevention and Public Health Service YES Partial YES YES Long-term Care NO NO YES YES Private Hospitals (General Outpatient) NO YES YES YES Home-based Curative Care YES YES YES YES General Outpatient Curative Care Partial YES YES YES 89 MALAYSIA NATIONAL HEALTH ACCOUNTS HEALTH EXPENDITURE REPORT 2011-2022