MALAYSIA NATIONAL HEALTH ACCOUNTS (MNHA): SUMMARY OF FRAMEWORK N ational Health Accounts (NHA) is a tool composed of a standard set of tables to capture the public and private sectors health expenditure flow within a country over a specified period. Information such as input, output and resource use obtained from this tool is essential to examine the performance of health system. Identical set of rules and methodology needs to be used to ensure information from NHA is comprehensive, consistent, comparable and timely. 2.1 THE MNHA CLASSIFICATION The MNHA Framework is based on international NHA classifications with minor modifications to suit local policy needs (Appendix Tables A2.1, A2.2, and A2.3). The data in all chapters (except Chapter 10) are based strictly on the MNHA Framework. The framework classifies all expenditures into three main entities: • Sources of financing (MS) • Providers of health care (MP) • Functions of health care (MF) Sources of financing are defined as entities that directly incur the expenditure and hence control and finance the amount of such expenditure. It includes the public sector expenditure encompassing the federal government, state government, local authorities, social security funds and other public entities, and the private sector consisting of private health insurance, managed care organisations, out-of-pocket expenditure, non-profit institutions and corporations. Providers of health care are defined as entities that produce and provide health care goods and services. These include categories of hospitals, nursing and residential care facility providers, ambulatory health care providers, retail sale and medical goods providers, public health programme providers and general health administration. Functions of health care are categorised as core functions of health care and health-related functions. Functions of health care include services of curative care, rehabilitative care, long-term nursing care, ancillary services, out- patient medical goods, public health services, health administration and health insurance. Health-related functions include capital formation, education & training of health personnel and research & development in health. 2.2 OVERVIEW OF TOTAL EXPENDITURE ON HEALTH (TEH) In the MNHA Framework, TEH comprises expenditures from both public and private sources, which consist of both ‘health expenditures’ and CHAPTER 2 2 MALAYSIA NATIONAL HEALTH ACCOUNTS HEALTH EXPENDITURE REPORT 2011-2022
all ‘health-related expenditures’ components. ‘Health expenditures’ as defined in the MNHA Framework consist of all expenditures or outlays of medical care, prevention, promotion, rehabilitation, community health activities and health administration and regulation with the predominant objective to improve health. Core function classifications reflect these under the codes MF1-MF7. ‘Health-related expenditures’ classification under the codes MR1, 2, 3 and 9 include expenditures of ‘capital formation of health care provider institutions’, ‘education and training of health personnel’, ‘research and development in health’ and ‘all other health-related expenditures. For easier understanding, components that make up TEH according to MNHA Framework are illustrated in Figure 2.1. FIGURE 2.1: Total Expenditure on Health in MNHA Framework Code Core Functions MF1 Services of curative care MF2 Services of rehabilitative care MF3 Services of long-term nursing care MF4 Ancillary services to health care MF5 Medical goods dispensed to out-patients MF6 Prevention and public health services MF7 Health programme administration and health insurance Code Health-Related Functions MR1 Capital formation of health care provider institutions MR2 Education and training of health personnel MR3 Research and development in health MR9 All other health-related expenditures 2.3 OVERVIEW OF CURRENT HEAL TH EXPENDITURE (CHE) To address the need for methodological consistency when comparing health expenditure across different countries, the World Health Organization (WHO), Eurostat and related international organisations of the Organisation for Economic Co-operation and Development (OECD) produced a manual known as “A System of Health Accounts”. The latest edition of this manual is known as the SHA 2011. It is essential to understand the differences when comparing data based on MNHA Framework to data based on SHA 2011 framework. As described earlier, the MNHA Framework captures and reports health spending as total expenditure on health (TEH), whereas current health expenditure (CHE) is used when reporting on SHA 2011. Health spending based on CHE has lower value as it excludes capital spending, education & training and research & development and other health related functions. Since 2017, both OECD and WHO countries have used CHE for international reporting and inter-country comparisons of national health expenditures. Components that make up CHE, according to SHA 2011, are illustrated in Figure 2.2. 3 MALAYSIA NATIONAL HEALTH ACCOUNTS HEALTH EXPENDITURE REPORT 2011-2022 FIGURE 2.2: Current Health Expenditure in SHA 2011 Framework Code Core Functions HC.1 Services of curative care HC.2 Services of rehabilitative care HC.3 Services of long-term nursing care HC.4 Ancillary services to health care HC.5 Medical goods dispensed to out-patients HC.6 Prevention and public health services HC.7 Health programme administration and health insurance 4 MALAYSIA NATIONAL HEALTH ACCOUNTS HEALTH EXPENDITURE REPORT 2011-2022
METHODOLOGY OF DATA COLLECTION AND ANALYSIS 3.1 GENERAL METHODOLOGY A general understanding of the methodology in NHA estimation provides a better appreciation of the data. The previous MNHA HER produced data from 2011-2021, and the current report contains data from 2011 to 2022. Data in this report may show some variations compared to the previous reports. Changes in the time series data may reflect the incorporation of recent developments with previous data from various censuses and surveys (when using secondary data); may reflect genuine structural changes; may be caused by variations in responses from multiple data sources at each cycle of estimation; or access to new data that is used to replace previous estimations. These variations are an acceptable phenomenon under NHA. Complete lists of the data sources are documented at every cycle of analysis (Appendix Table A1.1, A1.2). It is difficult to obtain a near 100% response rate from all data sources. Any improvements in data responses will minimise estimations of non-responders and reflects better true data. 3.2 D ATA COLLECTION AND ANAL YSIS The method of data collection and analysis used in this report conforms to the method used in the previous cycle, whereby detailed definitions of what constitutes health expenditure, institutional entities and types of disaggregation were drawn up based on inputs from several documents, committee meetings, and consultative advice from the internal and external MOH sources. Both primary and secondary data were used in this analysis (Appendix Table A1.1 and A1.2). Agencies from public and private sources provide primary data in several formats. These data were obtained through multiple MNHA surveys. The secondary data were retrieved from various data sources, reports, bulletins and other documents. All data were analysed separately by identified group of agencies. Upon verification, data were entered into various dummy time series spreadsheets. Verification of data is important as it affects the quality of final outputs. The data sets from each agency were processed differently depending on the availability and completeness. Data classification for each agency was carried out based on the tri-axial MNHA dimensions of sources, providers and functions. The MNHA Framework enables health expenditure to disaggregate to the lowest possible code. Any data gaps in each of these disaggregated data from each agency were subjected to imputation methods recommended by NHA experts. These imputation techniques may vary from agency to agency. The final analysis data of each agency were coded according to the MNHA Framework. State codes were also assigned to every set of analyses. All CHAPTER 3 5 MALAYSIA NATIONAL HEALTH ACCOUNTS HEALTH EXPENDITURE REPORT 2011-2022 stages of analyses were highly technical, involved several methods tailored to specific agencies and required a good understanding of the MNHA Framework. The data entry and analysis processes were carried out using Microsoft Excel and Stata statistical software. After initial data preparation, analysis, and coding, measures were taken to ensure data quality. Several additional verification methods are put in place before producing the final database. These involve validation of total estimates and a combination of codes for each data source prior to merging to produce the final database. Data from each agency were then collated. Subsequently, NHA data extraction is carried out to populate various tables and figures easily understood by policymakers and other stakeholders. Considering to continually improving NHA estimations and reporting, MNHA reviewed and refined its methodology in several phases. During the first round of refinement, analyses to standardise hospital reporting were applied. In short, this led to the inclusion of all costs incurred for ancillary services such as community pharmacy charges (drugs and non-durable products), surgical costs, laboratory tests and radiological investigations as curative care expenditures whenever they are delivered as part of a curative care service package. As defined in NHA, hospital care embodies all services provided by a hospital to patients. Under this, analysis of all public and private hospitals was disaggregated and reported as expenditure for in-patient, out-patient and day-care services only. On the other hand, expenditures incurred at standalone laboratories and radiological investigations are reported under another function code. This is strictly in keeping to definitions of functions codes under MNHA Framework for curative care services and provider of health care boundary for standalone ambulatory health care centres. Further refinement was carried out to address concerns of double counting. When producing a country’s health account, it is essential to recognise the equal importance of each dimension of the NHA. Focusing on collecting data from one dimension tends to underestimate expenditure as health spending from other entities via different NHA dimensions is not captured. It is essential to quantify all health expenditures from various information sources along all NHA dimensions. However, estimations of expenditure along more than one dimension increase the likelihood of double counting. In the Malaysian context, estimated total health expenditure for all public hospitals is obtained from the respective data sources who are also providers of health care services. In addition, surveys were done to collect health spending by various public and private sector employers/companies that also capture claims or reimbursements. It is significant to note that claims and reimbursement encompass expenditures for public hospitals’ curative care services. Therefore, after carefully scrutinising all details, the refined methodology is a downward revision to health care expenditures, resulting from the removal of various agencies’ reimbursements when it involves claims for treatment received at public MOH and non-MOH hospitals and clinics. Corresponding to this, all claims or reimbursement at these providers are grouped as in-patient, out-patient and day-care services. This enables MNHA to maintain detailed accounting of health spending that is mutually exclusive and standardised. All subsequent reporting of MNHA maintained the above-explained refinement. Peer review workshops are conducted annually to examine, discuss and verify the validity and reliability of the final data outputs of each agency. This involves validation of all codes and total estimation used for each data source prior to merging into a final database. This report only highlights some selected findings, which may be helpful in the health policy development and health planning of the country. Further detailed data extractions with cross-tabulations are usually produced based on policymaker’s and stakeholder’s requests. 6 MALAYSIA NATIONAL HEALTH ACCOUNTS HEALTH EXPENDITURE REPORT 2011-2022
3.3 DATA PROCESSING OF VARIOUS AGENCIES The methods used for data processing vary according to the availability, completion and source of data as follows: 3.3.1 Public Sector I. Ministry of Health (MOH) Health expenditure data of the MOH were obtained from the Accountant-General’s Department of Malaysia (AGD), under the Ministry of Finance (MOF). The Accountant- General (AG) raw database for the MOH is the primary source of data whereby expenditure data is entered as a line item. All health expenditures are disaggregated into the tri-axial coding system under the dimensions of sources of financing, providers and functions of health care based on the MNHA Framework, omitting double counting. Assigning of MNHA codes is based on examining available data and additional details captured via MNHA surveys. II. Ministry of Higher Education (MoHE) Health expenditure under the MoHE includes two main functions. Firstly, provision of health care services by university hospitals for the general population and outpatient medical clinics meant for students and the university community. Second, health expenditure from this agency is on health- related training and research expenditure. Other than these institutions, data on the cost of training health professionals are also obtained from various private training colleges, Public Service Department (PSD) and other agencies. III. Other Federal Agencies (including Statutory Bodies) The agencies under “other federal agencies” currently consist of twenty two public agencies, which include the National Anti- Drug Agency (AADK), Prison Department, Malaysia Civil Defence Force, Pension Department of Public Service Department (KWAP), National Heart Institute of Malaysia, Social Welfare Department of Malaysia, Department of Orang Asli Development, National Population and Family Development Board Malaysia, National Institute of Occupational Safety and Health Malaysia (NIOSH), Department of Occupational Safety and Health Malaysia (DOSH), National Sports Institute of Malaysia, Ministry of Finance (MOF), Ministry of Science, Technology and Innovation (MOSTI), federal statutory bodies, higher education institutes, Pilgrims Fund Board, National Disaster Management Agency (NADMA), Majlis Keselamatan Negara (MKN) and Emergency Medical Rescue Services (EMRS). The expenditure on health of other federal agencies (including statutory bodies) was captured through MNHA survey questionnaires. Data from this survey also assist in estimating and disaggregating expenditure along with the providers and functions of health care dimensions for agencies with incomplete or no data. Expenditures under this group are mainly for curative care services, retail sales and medical goods, and research. IV. Local Authorities Health expenditure data of the local authorities encompass 155 agencies of local/ municipal governments in Malaysia. Health expenditure data captured from this entity includes expenditure on services provided to the general public and expenditure that covers health care services provided for staff. V. (General) State Government This consists of health expenditure by all thirteen state governments and three Federal Territories, which include Kuala Lumpur, Putrajaya and Labuan. Most state expenditure is analysed based on services provided to the general community, mainly for preventive care such as environmental 7 MALAYSIA NATIONAL HEALTH ACCOUNTS HEALTH EXPENDITURE REPORT 2011-2022