This is MOH Deputy Director Dr Rozita Halina Tun Hussein's presentation at the Prince Mahidol Award Conference, January 2012. She is speaking on Malaysia's experience in formulating a health care rationing method. Healthcare rationing is a well-known fact of Insurance based healthcare systems. But the government insists that Malaysians will get all the healthcare they need for free. This is a blatant lie!

1. Implicit & Explicit Benefit
Implicit & Explicit Benefit
Package: Pros & Cons
Package: Pros & Cons
Dr Rozita Halina Tun Hussein
Unit for National Health Financing
Unit for National Health Financing
Planning and Development Division
Ministry of Health, Malaysia
rozitahalina@moh.gov.my
it h li @ h
1
Overview
• The context of Malaysia
• Definitions and Scope of Benefit Package (BP)
Definitions and Scope of Benefit Package (BP)
• Implicit BP Pros & Cons
• Explicit BP Pros & Cons
• Conclusion
• References
Acknowledgement Dr Munizam
Acknowledgement – Dr Munizam Abd Majid, Dr Mastura
Majid, Dr Mastura
Mohd Tahir and Dr Zakiah Zainuddin 2

2. Malaysian Health System
3
Life Expectancy at Birth
Female, 2009
,
76.5
Male,2009
71.7
4
Source:
Source: Department of Statistics, Malaysia

3. Selected Vital Statistics
80.0
Malaysia 1957‐2006
M l i 1957 2006
70.0 IMR
60.0
50.0
40.0
NMR
30.0
20.0
CDR
10.0
TMR
0.0
1957 1960 1970 1980 1990 1995 1999 2001 2002 2003 2004 2005 2006
Source : Department of Statistics, Malaysia
Targeting of Public Spending
Source: Rozita Halina, 2000
6

4. Poverty Impact of Health Expenditures
Pre and post OOP payment income, Malaysia 1999
200
180
ultiples of $1 PL
L
160
140
sumption as mu
120
100
per capita cons
80
60
40
20
0
0.00
0.04
0.09
0.12
0.16
0.19
0.23
0.26
0.29
0.32
0.35
0.38
0.41
0.44
0.47
0.50
0.52
0.55
0.58
0.60
0.63
0.65
0.68
0.70
0.73
0.75
0.77
0.79
0.81
0.83
0.85
0.87
0.89
0.91
0.93
0.94
0.96
0.98
0.99
cum. proportion of persons in ascending order of consumption
Source Ng CW - Equitap $1.08 PL Pre OOP consumption Post OOP consumption 7
Primary Health Care
Comprehensive Deconcentrated
Comprehensive Deconcentrated System
Mother and Child
Family Planning
Outpatient
Home Visits
Dental
2000
1980 Pharmacy
Mother and Child Lab
Child w Special Needs
1960 Family Planning
Outpatient
Reproductive Clinic
Elderly
Adolescent
Mother and Child Home Visits Geriatric
Dental Emergency
Family Planning
Health informatics
Outpatient
O i Pharmacy Occupational Health Clinic
Lab Diabetic Clinic
8

5. 1Malaysia clinics and Community clinics
9
Health Services at District Level
DISTRICT HEALTH OFFICE
No. : 139*
OUTREACH SERVICES
FLYING DOCTORS
HEALTH CLINIC
No. : 807*
Coverage: 20,000 pop
COMMUNITY HEALTH CLINICS / KLINIK
DESA
• No 2158*
No. : 2158*
• Coverage: 4,000 population
MOBILE TEAM
10
* DEC 2006 * Dec 2006

6. SECONDARY / TERTIARY CARE
For the regionali ed services, FOCUS is given to 6
For the regionalized services, FOCUS is given to 26
specialty / subspecialty services:
1. RESPIRATORY MED. 10. NEUROLOGY 20. UROLOGY
2. INFECT. DISEASES 11. ENDOCRINOLOGY 21. PAEDIATRIC SURGERY
3. RHEUMATOLOGY 12. ONCOLOGY 22. PLASTIC SURGERY
4. HEPATOLOGY 13. UPPER GI SURG. 23. CARDIAC PERFUSION
5.
5 PALLIATIVE
PALLIATIVE 14.
14 COLORECTAL SURG.
COLORECTAL SURG ANAES.
ANAES
MEDICINE 15. HEPATOBILIARY SURG. 24. NUCLEAR MEDICINE
6. HAEMATOLOGY 16. BREAST/ ENDOC SURG. 25. REHABILITATION
REHABILITATION
7. GASTROENTERO. 17. VASCULAR SURGERY MEDICINE
8. CARDIOLOGY 18. NEUROSURGERY 26. FORENSIC MEDICINE
9. GERIATRIC 19. CARDIOTHORACIC
SURGERY
Other sub-specialisations and areas of
competence continue to be developed. 11
CENTRES OF EXCELLENCE
• Collaboration with
US

7. Health System Sustainability
Public Private Expenditure on Health
1997 – 2009 (2011 value)
1997 2009 (2011 l )
25.00 5.0 5.00
4.4 4.50
4.2 4.2 4.1
4.1
3.8 3.9
20.00 3.7 19.1 4.00
17.3
3.3 16.3 3.50
3.2 16.1
3.1 15.2
2.9 14.6
15.00 3.00
12.9
12 9 15.9
12.0 14.8 2.50
11.4 14.2
13.4
10.00 9.5 12.5 2.00
8.6 11.6
10.6
10 6
7.8 7.7
1.50
9.1
8.2
5.00 7.6 1.00
6.1 6.8
6.0
0.50
0.00 0.00
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Public Exp (RMbill in 2011 RM value) Private Exp (RMbill in 2011 RM value) THE as % GDP
13
Source – MNHA
Three Dimensions to Consider When
Improving Universal Coverage
Improving Universal Coverage
Source : Health System Financing, WHO Report, 2010 14

8. Components of 1Care for 1Malaysia
1. Service Delivery Reforms
• Increase quality of care
• Public & Private healthcare delivery
• Family doctor for each individual
Family doctor for each individual
• Gatekeeper to higher level
• Defined benefit package
3. Financing Reforms 2. Organisational Reforms
• Mixed financing • Public Sector autonomyy
SHI (by NHFA) • Streamlining MOH
General taxation  Stewardship
• Purchaser Provider Split Governance
• Relevant PPM
l Public health services
• Incentives Research
• Pay for Performance Training
15
DEFINITION of BENEFIT PACKAGE
• BP refers to ‘the totality of services, activities, and
P refers to the totality of services, activities, and
goods covered by PUBLICLY FUNDED
y/ y
statutory/mandatory insurance schemes’ – EU Health
BASKET project
• Essential BP aims to concentrate scarce resources
o te e t o s
on interventions which provide the best 'value for
c p o de t e best a ue fo
money'.
– often expected to achieve multiple goals:
often expected to achieve multiple goals:
improved efficiency; equity; political empowerment,
accountability, and altogether more effective care.
(WHO 2008)
16

9. SCOPE of BENEFIT PACKAGE (BP)
• BP ‐ in low‐income country consists of a limited list
of services or interventions while, in richer
countries packages are often described according
to what they exclude.
• Essential Benefits package (BP) will become the
p g ( )
standard for health coverage and will be used as
g
the basis for establishing the different benefit levels
of plans that will be offered … the minimum that all
new health plans have to cover (Families USA Sept 2009
about Health Reform Legislation – benefits in different health
plans in the health insurance exchange) 17
WHAT IS IMPLICIT BP?
• Broadly defined general categories of care, and
then leave the more specific decisions to health
then leave the more specific decisions to health
professionals and/or politicians.
• Utilised in
– New Zealand prior to health reforms in the early
New Zealand prior to health reforms in the early
1990s (Wong & Bitrán 1999)
– Primary Healthcare Services in Britain (Clarkeburn 1998)
– Malaysia’s public health care sector
Malaysia s public health care sector
18

10. Characteristics of Implicit BP
i. Rationing without a (single) defined rationing plan
ii. Implicit rationing is implemented by using one or more
subtle ways to ration
iii. In an implicit rationing model, no one person or
institution takes responsibility for making resource
allocation choices in health care = 'invisible' rationing.
ll ti h i i h lth 'i i ibl ' ti i
iv. People directly affected or making these implicit rationing
choices do not know which choices have actually been
h d k h h h h ll b
taken or on what grounds.
v. Inclusions of the health service are often publicly known,
while exclusions are performed implicitly.
vi. Implicit rationing choices are localized. Health care
providers = role as rationing agents. (Clarkeburn 1998)
19
IMPLICIT ‐ Pros
• Increase population coverage by limiting service
coverage (Ham & Coulter 2001).
• Allows flexibility (Wong & Bitrán 1999)
Allows flexibility (Wong & 1999).
• May actually be a better way of dealing with
difficult and complex issues. (Hunter 1995)
difficult and complex issues (H t 1995)
• Minimize political resistance ‐ No explicit
exclusions to serve as a focal point for opposition
(Wong & Bitrán 1999).
• Politicians are shielded/praised from the impact
of decisions about who not to treat and who to
treat (Hunter 1995).
20

11. IMPLICIT ‐ Pros
• Possibility of securing and maintaining the
ideal/idea of a health care system that will in all
instances do the most for every single individual
(Clarkeburn 1998)
• At the point of service maybe more sensitive to
– the complexity of medical decisions and
p y
– the needs and personal and cultural preferences of
p
patients (Mechanic 1995)
( )
In Malaysia, health care providers are the key
I M l i h lth id th k
decision‐makers about demand for health care 21
IMPLICIT ‐ Cons
• Places a great responsibility on health care
l ibili h lh
providers
• Given only minimal guidelines
• May sacrifice their professional integrity
May sacrifice their professional integrity
• Uncertainty on actual services covered
• chance of patients receiving most appropriate
health care can be influenced by their luck in
finding the right healthcare provider and/or by /
their place of residence, as local health
authorities may have made differing decisions on
a thorities ma ha e made differing decisions on
the services provided (Clarkeburn 1998) 22

12. IMPLICIT ‐ Cons
• This approach may not be able to achieve an
efficient allocation of resources, since health
planners, clinicians and politicians may have
conflicts of interest and differing priorities in
conflicts of interest and differing priorities in
determining which services to provide
• Tool for political mileage
lf l l l
• Own incentives may not closely match with
Own incentives may not closely match with
those of society as a whole (Wong & Bitrán 1999).
23
WHAT IS EXPLICIT BP?
• Identifying and using standard specific criteria(s) to
identify services which should receive priority
d f h h h ld
– the identification of community needs and preferences
– the criteria of cost effectiveness and/or efficiency
– criteria that a health problem involves a large number of
criteria that a health problem involves a large number of
people, services are available and effective, and quantified
g
targets can be set
• A positive list of included interventions or a negative list
of excluded interventions
of excluded interventions
• When governments decide to purchase health care from
private or public providers, BPs must necessarily be
explicit 24

13. Explicit ‐ Pros
Waste fewer
resources,
Financial More
protection and technical Greater
beneficiary efficiency accountability
satisfaction
ti f ti
Better legitimacy
Citizen of rationing
empowerment - decisions, fair,
right to demand democratic
Get more What can
health
for your money,
explicit BPs
li it BP More
potentially equity
Value for
money y achieve?
25 (Bitran& Giedion, 2009)
EXPLICIT ‐ Pros
In Chile:
• Quality: Each health problem has a specific
p
protocol developed in a process of reviewing
p p g
clinical guidelines and adjusting to available
human and technical resources designed to
human and technical resources – designed to
be as high quality as is realistic in Chilean
conditions.
• Timeliness: Protocols have maximum times
for diagnosis, treatment and follow‐up. If
for diagnosis treatment and follow up If
provider fails to meet the timing, it is required
to pay an alternative provider.
to pay an alternative provider
(Bossert 2009) 26

14. EXPLICIT ‐ Pros
In Italy, a clear definition of the benefits provided
In Italy a clear definition of the benefits provided
by the statutory system maybe beneficial for
several reasons:
several reasons
1. it can contribute to a better allocation of
resources, (allocative efficiency)
2. helps reassure beneficiaries about their rights
2 helps reassure beneficiaries about their rights
and responsibilities, and
3. facilitate the development of supplementary
insurance
(Del Vecchio M 1997 & Torbica & Fattore 2005)
27
EXPLICIT – Cons
• May result in more resources being allocated to the health
g
care budget (Ham & Coulter 2001)
( )
– What is the unmet need, what further investments are needed,
actual availability of services (addressing equity of access)
• Likely to focus conflict and dissatisfaction, politically
destabilizing. (Mechanic 1995). In the USA, ‘attempts to ration
health care explicitly are political dynamite
health care explicitly are ‘political dynamite’ ((Ham & Coulter 2001))
& l
• Explicit priority setting is a continuing process which is not
amenable to once and for all solutions Have put in place
amenable to ‘once and for all’ solutions. Have put in place
mechanisms to ensure that the issues involved are kept under
CONTINUOUS REVIEW (Ham 1997)
• Criteria approach ‐ may be difficult for the population to
agree on what criteria to use, difficulties in measurement
(Wong & Bitrán 1999).
(Wong & Bitrán 1999)
28

15. EXPLICIT ‐ Cons
• New Policy Instruments and Technical solution
– Clarity about objectives, outcomes
Clarity about objectives outcomes
– Good information/ data/ health technology assessment
– Evidence base
– Ability and methodology to measure performance
• Capacity and Knowledge of policy maker and other
p y g p y
stakeholders
• Effective “vehicles” for BP implementation
Effective vehicles for BP implementation
– Clinical or quality assurance protocols, including for referrals.
– Contracting providers to provide the essential package.
– The regulation and accreditation of individual facilities.
– Supervision.
– Assigning inputs t
A i i i t to meet the needs of the BP – i f t t
t th d f th BP infrastructure
plans, essential equipment lists etc. (Ham & Coulter, 2001) 29
Malaysia – Implicit to Explicit BP
• Criteria – Disease burden, waiting times to tx
• Methodology – representation, voice, data, source
• Financing – who bears the cost
Fi i h b h
• Understanding – services to be provided and not
g p
• Criteria to document what is provided now
–B dC
Broad Categories Vs Specific Service/Product/Procedure
i V S ifi S i /P d /P d
– Technology (Minimum threshold), CPG, Clinical pathway
– Indications, Population , Provider, Referral threshold
– Current waiting times (assessment of unmet need)
Current waiting times (assessment of unmet need)
– Cost and cost effectiveness, source of funding, co‐pay 30

16. EXPLICIT – Cons
• Potential for distress for frontline providers
ote t a o d st ess o o t e p o de s
caused through rationing openly
• Wh th
Whether explicitness is always the best
li it i l th b t
approach at the consultation level??
• Professionals need further training and support
to deal with the stressful nature of making
to deal with the stressful nature of making
rationing decisions openly. (Smith, Coast & Donovan, 2010)
• Implementing an BP is not just a technical
l h l
exercise – political and institutional processes
need to be engaged 31
Conclusion
• Many comparison of merits and difficulties
p p p g
with implicit and explicit benefit packages.
• Moot point with purchaser provider split
• R
Recently, the issue now is how best to
l h i i h b
develop a more explicit BP
• Globally, a mixture of implicit and explicit BP –
how to strike the balance.
how to strike the balance
32

17. References
• Del Vecchio M (1997) Guaranteed entitlement to health care: an Italian point of view. In: Lenaghan
J (ed) Hard choices in health care. BMJ Books:London
• Ham, C. Coulter, A. 2001. Explicit and implicit rationing: taking responsibility and avoiding blame for
health care choices. Journal of Health Services Research & Policy Vol 6 No 3, 2001: 163 169
health care choices Journal of Health Services Research & Policy Vol 6 No 3 2001: 163–169
• Wong, H. Bitrán, R. 1999. Designing A Benefits Package. World Bank Institute.
• Hunter, D.J. 1995. Rationing health care: the political perspective. Br Med Bull (1995) 51 (4): 876‐
884.
• Mechanic, D. 1995. Dilemmas in rationing health care services: the case for implicit rationing. BMJ
h l h lh h f l
1995:310:1655‐9
• Torbica, A. Fattore, G. 2005. The “Essential Levels of Care” in Italy: when being explicit serves the
devolution of powers. Eur J Health Econom 2005 ∙ [Suppl 1] 6:46–52
• Guerrero, R. Ornelas, H. A. Knaul, F. M. 2010. The world health report. Health system financing.
Technical Brief Series ‐ Brief No 13. Breadth and depth of benefit packages: lessons from Latin
America. World Health Organization.
• Smith, A. O. Coast, J. Donovan, J. 2010. The desirability of being open about health care rationing
decisions: findings from a qualitative study of patients and clinical professionals. Journal of Health
d ii fi di f lit ti t d f ti t d li i l f i l J l f H lth
Services Research & Policy Vol 15 No 1, 2010: 14–20
• Sabik, L. M. Lie, K. R. 2008. Priority setting in health care: Lessons from the experiences of eight
countries. International Journal for Equity in Health 2008, 7:4
• Alexander GC, Werner RM, Ubel PA: The Costs of Denying Scarcity. Archives of Internal Medicine
Alexander GC Werner RM Ubel PA: The Costs of Denying Scarcity Archives of Internal Medicine
2004, 164:593‐596.
• Fleck LM: Rationing: Don't Give Up. Hastings Center Report 2002, 32:35‐36.
• Fleck LM: Just Caring: Health Reform and Health Care Rationing. Journal of Medicine and
Philosophy 1994, 19:435 443.
Philosophy 1994 19:435‐443
• Ham, C. 1997. Priority setting in health care: learning from international experience. Health Policy
42 (1997) 49–66
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Thank you
Th k y
34