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Malaysia Audit Finding: Health sector - 2018



The Emergency & Trauma department (ETD) at Malaysian hospitals are understaffed, overcrowded, underfunded and do not have enough equipment to provide proper levels of care.
The Report by the National Audit Department also flagged the issue with funding for ETD, which it deemed “insufficient”. Among others, shortage of funds also means hospitals are unable to properly replace and procure new equipment.
“The provision of financial allocation which is insufficient, may affect the ETD’s service efficiency,” the Audit Report released on 15th July 2019
The Ministry of Health (MoH) said between 2016 and 2018, the Ministry requested for RM 96.95 millions for this purpose, but only received RM 20.32 millions or 21% of the requested amount.
Therefore, MoH resorted to leasing of some equipment for radiology, general surgery, orthopaedic, anaesthesiology, and intensive care. “This (leasing) method is a pioneer project which will be widened to fulfill the medical equipment needs in ETD for a five-year period beginning 2019,” MoH said.
Reviewing 4 out of 38 hospitals across Malaysia that fall into the Level of Care III and IV categories, the National Audit Department found that the number of patients at these hospitals exceeded the level of care by between 5.7% and 95.6%, causing congestion.
In addition, only 58.7% to 74.5% of patients were treated within four to six hours. The audit also found 917 cases of "access block", where patients were unable to be moved to medical wards.
There are 140 hospitals nationwide as of 2018. In 2017, these hospitals received 8.01 million ETD patients, accounting for 38.1% of total outpatients in Malaysian hospitals.
From the 140 hospitals, 80 are Level of Care I (non-specialist hospitals); 22 are Level of Care II (specialist hospitals with 150-200 ETD patients daily, and 54,750-73,000 annual patients); while 24 are Level of Care III (main specialist hospitals with 200-300 ETD patients daily, and 73,000-109,500 annual patients).
The remaining 14 are categorised as Level of Care IV, receiving over 300 ETD patients daily and over 109,500 patients every year. These are state hospitals and the Kuala Lumpur Hospital.
According to the Auditor-General 2018 Report Series 1, in 2018, ETDs are generally short of staff by 11.6% to 53.1%. The biggest shortage comprises emergency specialists (75.6%-79.5%), followed by medical officers (41.2%-64.6%); assistant medical officers (2.6%-33.9%) and trained nurses (17.4%-67.1%).
This resulted in available staff being required to work overtime to handle the high workload, which also undermines the quality of service, as well as the quality of life of ETD officers and staff.
Interestingly, the audit report also cited a 2018 study on the burnout syndrome among ETD doctors, which found that about one in five (21.5%) respondents exhibited burnout syndromes, while 35.5% of respondents experienced emotional burnout.
In terms of medical equipment, ETDs only had 104 out of a list of 212 equipment they needed to have, which is less than half at 49.1%, according to the Emergency Medicine & Trauma Services Policy (EMTSP),
“ETD also had to provide between 8 and 50 units or two to five times the number of additional beds/sofas, because the existing available beds for treatment purposes in the Yellow Zone, Red Zone and the Observation Ward/Bay could not cope with increasing patient numbers,” the Audit report said,
The Audit also opined that the increase in patients, particularly those with non-emergency cases, had undermined the efficiency of ETD services, including in respect of available beds, staff workload and insufficient equipment.
In response to the audit findings, the MoH said it is updating the EMTSP to have more detailed sub-categorizations under the Red Zone — which has cases that incur more manpower and treatment costs than those in the Green Zone.
The Ministry said the congestion at ETD is due to patient numbers generally increasing between 2% and 3% annually, nationwide.
MOH also noted that while ETD is technically allowed to use the Triage Away policy to reduce congestion, the ministry does not enforce this policy on patients, as it also adopts the ‘No Wrong Door Policy’. 
“In the mid- to long-term, society should be inculcated with knowledge relating to the use of emergency and trauma medical services only being for cases categorised as emergencies,” MoH said.
/theEdge 15-07-2019


Disclaimer: Views or opinions expressed are solely those of the Author and should be used with discretion. The Author shall not be held liable for any acts or omissions arising from the use of the information. The user will be personally liable for any damages or other liability arising hereof.


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Public-Private Partnership for Healthcare transformation



MALAYSIA’s public healthcare needs are bursting at the seams and available tax funds are not enough to meet the growing demands as cost of care keeps increasing. Adding to the challenge is the country’s current high debt level and economic downturn.
Against this backdrop, the Health Minister Datuk Seri Dr Dzulkefly Ahmad announced in late March 1) the setting up of a seven-member Health Advisory Council to look into public-private partnership (PPP) initiatives to meet Malaysia’s healthcare needs 2) looking into a National Health Insurance scheme to get more funding. Some stakeholders, however, are urging the government 3) to plug the tax loopholes, so that more funds can be retained for the country’s healthcare needs 4)  examine the areas of conflict of interests affecting public healthcare delivery.
Noting that the World Bank and the International Monetary Fund have recommended the PPP approach to address the shortfall in healthcare funds, Dr Jeyakumar expressed concern that neo-liberal solutions are generally recommended, where charging people for healthcare is deemed good as it will encourage people to adopt a more healthy lifestyle.
He also pointed to a recent Harvard study funded by the World Bank, which recommended that the government devolves more of its healthcare functions to market players while it focuses on regulation.
In Malaysia, the corporate tax rate was 40% until 1988 but it was gradually reduced to the current 24%, and the government has indicated that it will be brought down further to compete with Singapore’s 18% and Thailand’s 19% rates.
“There is competition among countries to cut down corporate tax and attract investors and the tax collected is not enough to fund developmental projects for the people,” he says, noting that this has led to many countries, including Malaysia chalking up huge sovereign debts.
Contributing further to the fund shortage is the worldwide trend of keeping budget deficits to below 3% of the GDP.
Another issue is tax evasion by business owners who resort to various tactics to avoid paying taxes, including royalty payments and scheme transfer pricing - so that profits made in a particular country are repatriated to a tax haven through grossly exaggerated fees.
This is generally supported by the forum with some saying that the government should also look into a more progressive taxation system and review our taxation laws.
Conflicts of interest 
Health policy analyst Dr Chan Chee Khoon raised the issue of government agencies at the federal and state levels having controlling stakes in major for-profit healthcare enterprises.
While government-linked companies (GLCs) built up their stakes in the commercial healthcare sector, a succession of health ministers had argued that Malaysians who could afford it should seek private healthcare services as this would allow the government to target its limited healthcare resources on the “really deserving poorer citizens,” he says.
He cites the example of Kumpulan Perubatan Johor, a large diversified healthcare conglomerate which includes the largest chain of private hospitals (26) in the country, spawned by the Johor state government through its corporate arm the Johor Corporation.
Another is the IHH Healthcare Bhd, the healthcare subsidiary of Malaysian federal government’s sovereign wealth fund Khazanah. It emerged as the second largest listed private healthcare provider in the world - (by market capitalisation, US$8.06bil (RM33.5bil) – when it added Turkey’s largest private healthcare group Acibadem to its recently merged Parkway-Pantai chain of private hospitals in Malaysia and Singapore.
That means, the government, through GLCs at federal and state levels, own and operate three parallel systems; the Health Ministry facilities, corporatised hospitals (National Heart Institute, university hospitals) and IHH chains of commercial hospitals, says Dr Chan, calling it a conflict of interest affecting public healthcare delivery.
As he puts it, GLCs now control more than 40% of “private” hospital beds in Malaysia.
“How are conflicts of interests playing out, as the state juggles its multiple roles as funder and provider of public sector healthcare, as regulator of healthcare system and as pre-eminent investor in the private health services industry?” he says.
The attempted acquisition of the National Heart Institute by Sime Darby in 2008 is a revealing instance of disparate priorities, he says.
Dr Chan also notes the continuing poaching of staff from the public sector which exacerbates the already burdensome workload of its remaining staff.  
Hence, it is important for the government to scrutinise the PPP projects that it wants to take on, and consider the impact it has on public healthcare sector, adds Dr Jeyakumar.
Dr Chan says GLCs should be reoriented to become a source of high quality, no frills, medically necessary care at medium cost, to act as a price bulwark to rein in escalating, exorbitant charges in other commercial healthcare enterprises.
The crucial role for the government should include an oversight and regulation of an evolving system of healthcare provision and financing such that all Malaysians and other eligible beneficiaries continue to enjoy access to equitable healthcare on the basis of need, and not ability to pay.
Instead of a National Health Insurance, he says an alternative option which relies on a more progressive taxation regimes to improve universal access to quality care on the basis of need should be considered as it is notably absent from the options under consideration.
Reducing cost inefficiency
One way to manage healthcare cost better is to have a primary care physician to diagnose and treat patients at at the clinic level. But most Malaysians do not have one, and have to “shop” around by going to government clinics, private GPs and private specialists and this affects continuity of care and inhibits interventions to promote health and prevent disease, says Dr Jeyakumar.
Malaysia’s treatment oriented approach results in poorer outcomes and less cost effective treatment for non-communicable diseases (NCDs), he adds.
According to Malaysian Medical Association’s Private Practice Section chairman Dr R. Thirunavukarasu, the government can offload some of these patients who go for outpatient treatment in government hospitals to some of the underutilised 7,000 GPs nationwide who can monitor the patients’ NCDs.
Academy of Family Physicians of Malaysia president Assoc Prof Dr Mohammad Husni Jamal believes GPs must go through some courses to beef up their expertise as a generalists, like it is done in Britain, which then reduces unnecessary costly specialists’ attention.
Getting GPs to play a role in screening patients for NCDs is welcome as an acceptable form of PPP while the government can buy some services from the private sector depending on the price, he says.
Dr Chan cautions that in a profit-driven risk-rated insurance scheme, the people who need healthcare most, cannot access it.
The case of MySalam insurance for the B40 low income group excluded those with pre-existing conditions such as Alzheimer's, cardiomyopathy (heart disease), coma, if a patient is diagnosed before Jan 1, he says.
Dr Chan, who is also involved with Citizens’ Health Initiative, says that the Health Advisory Council should include laypersons and representatives of civil society organisations. 
Malaysian Pharmaceutical Society president Amrahi Buang agrees, sharing that in the community, pharmacists are among the first to respond to symptoms, with patients going to them first to purchase medicine to address their ailments.So it is important to also consider the role of pharmacists in healthcare, he says.
Besides careful adoption of PPP, some in the forum say more efforts have to be made to move Malaysians towards adopting a healthy lifestyle from a young age so that they grow old with less health problems that wipe out their life savings.
As Amrahi puts it, there is a need for a national health policy for the country to move forward - one that will push it towards preventive care, rather than curative.
 
/theSTAR 23-06-2019
 
Disclaimer: Views or opinions expressed are solely those of the Author and should be used with discretion. The Author shall not be held liable for any acts or omissions arising from the use of the information. The user will be personally liable for any damages or other liability arising hereof.


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WHO: Global drug price transparency resolution



The 72nd World Health Assembly's resolution on improving the transparency of markets for medicines, vaccines, and other health-related products and other technologies was adopted on Tuesday, 28 May, 2019 in Geneva, Switzerland.
The Malaysian Health Ministry welcomed this landmark resolution as it is a first step towards a more open dialogue about price transparency to improve access to medicines for the Country as well.
"This move will help strengthen our government's negotiating position and enhance our ability to obtain more affordable drugs for our people. The Ministry believes that a sustainable fairer pricing system is needed for both health systems and pharmaceutical industries," said the Director General, Datuk Dr Noor Hisham
He said the Ministry will continue its efforts to improve universal access to medicines and affordable medicines as one of the components in the National Medicines Policy, in line with its commitment to universal health coverage (UHC) that ensures universal access of medicine to the people.
However, one of the initial proponents of the resolution on requiring transparency in R&D costs was not achieved.
Third World Network legal adviser Sangeeta Shasikant said that it did not address the secrecy issues but it was a step forward towards price transparency and the WHO has a firm mandate to support member states to achieve this.
"An urgent next step is full transparency in R&D costs," she said.
Another part that was watered down, is for member states to take measures to share net prices of health products from manufacturers when the initial proposal was for prices to be shared across the supply chain.
The resolution was adopted after intense negotiations with member states to agree with the draft resolution proposed by Italy.
Malaysia is one of the initial six co-sponsoring nations, along with Greece, Serbia, Spain and Uganda.
The resolution gradually gained support from a total of 19 countries.
It urged member states to undertake measures to publicly share information on prices and reimbursement cost of medicines and improve the public reporting of the patent status information and marketing approval status, among others.
Among the countries that have disassociated themselves from the adoption of the resolution were Germany, the United Kingdom and Hungary. The United States, surprisingly, being a home to several large pharmaceutical companies, approved the resolution.
/theSTAR 29-05-2019


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Pushing for Drug Transparency



Access to medicines has long been considered a developing country issue of vaccines and basic 
medicines. But the rise in chronic diseases and expensive life-saving treatments is bringing the 
access debate to rich countries worried about the burden on healthcare budgets.  

This has become more important as Countries face the huge challenge of rare diseases and expensive treatments for diseases like cancer.

For example, in Switzerland, the cost of medicine per person has increased by 13% in just three yearsto CHF814 in 2017. The costs are largely driven by oncology and expensive combination therapies,
explained the Federal Office of Public Health (FOPH) at a press conference earlier this month in May2019

The FOPH estimates that nearly half of the 90 or so requests for approval last year were for 
treatments exceeding CHF100,000 ($99,097) per person per year.

Ahead of the World Health Assembly in Geneva,  towards end May 2019, an Italian draft resolution to end secrecy around drug pricing has already ruffled feathers 
among some governments and industry players.

The resolution proposed by Italy’s Minister of Health Giulia Grillo in February, 2019 urges the World Health Organization (WHO) and governments to boost transparency in four areas: drug prices, R&D costs, clinical trial data, and patent information.

Supporters of the resolution argue that transparency is essential to determine a fair price for 
medicines and ultimately make them more affordable. A recent OECD report on the industry 
reinforced this, stating that, “R&D costs and pricing structures are often opaque, raising legitimate 
questions about the value offered by some increasingly costly new treatments.”

While transparency has been discussed in global health circles for years, Swiss Global Health 
Ambassador Nora Kronig said that 
seeing transparency as a way to improve access 
to medicines is a new development.

WHO's definition of a fair drug price:

A ‘fair’ price is one that is affordable for health systems and patients and that at the same time 
provides sufficient market incentive for industry to invest in innovation and the production of 
medicines.
  

Is there such a thing as a fair price?

What is a fair price for drugs has become the question shadowing the discussions on transparency. 

Companies have typically defended high prices by pointing to much needed investments in research 
and development. But more research from the WHO, Switzerland and elsewhere shows that prices aredisconnected from costs and that drug company profits continue to rise.

Companies like Novartis and Roche have even said that costs are not the best way to determine prices

With new gene therapy treatments that cure diseases with a single treatment, they are calling for a 
shift to a value-based model based on patient outcomes and savings to hospitals and health systems rather than cost base.

Basically value-based pricing is a strategy of the pharmaceutical industry to avoid unveiling their real investment cost as alleged by some quarters.  

/23-05-2019

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Malaysia: Universal Health Care Coverage



Malaysia plans to overcome the challenges of achieving universal health coverage (UHC), says the Minister of Health, Datuk Seri Dr Dzulkefly Ahmad.

This will be through the implementation of the Enhanced Primary Health Care programme which addresses the increasing non-communicable diseases (NCDs) and mental health cases.

He also said the government was committed to achieving UHC especially for the vulnerable and underserved people within the population and this would be done through the Peka B40 programme for the low income group.

Malaysia shall continue to do whatever it takes to deliver high quality healthcare to all its people, and to reach each one of them.

"UHC is about equity and access to healthcare services for all, without incurring catastrophic financial hardship," he said at the 72nd World Health Assembly in Geneva on Tuesday, May 21, 2019

Dr Dzulkefly said that the 2017 Global Monitoring Report on Tracking Universal Health Coverage showed that Malaysia scored 70% in the UHC service coverage index.

However, its out of pocket (OOP) expenditure stood at 38% in 2018 although the WHO recommends that the OOP expenditure should be at around 20%

He said the government will also strengthen public-private partnership through the Health Advisory Council, which comprises eminent individuals including, but not limited to, the private medical fraternity.

"We will also address the sustainability of the existing health financing system, which is predominantly tax-based," he said.

Dr Dzulkefly said Malaysia will also enhance data quality and carry out data analytics on the available health indicators by utilising its centralised data storage system, MyHealth Data Warehouse (MyHDW).

Among the challenges that Malaysia faced in order to sustain UHC were the increasing disease burden involving communicable diseases (CDs) and NCDs, emerging ageing population and increasing workload in public facilities, said Dr Dzulkefly.

This is made more difficult with scarcity of financial and human resource which hamper efficient delivery, he added.

"Malaysia also faces continuous maintenance of health facilities, equipment and ICT infrastructure and the lack of capacity to monitor and evaluate the implementation of UHC," he said.

However, Dr Dzulkefly said that “leaving no one behind” has been the core of the government's policy-making.

The Sustainable Development Goals have been prioritized across the ministries in Malaysia and they are seriously looking at ways to help the people further.

/theSTAR 21-05-2019

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Wolbachia-infected mosquitoes as a new tool to contain Dengue



The government wants to stop fogging in selected areas in order to enable aedes mosquitoes to breed freely. 


Instead, mosquitoes infected with the Wolbachia virus will be released in 10 localities in the Klang Valley from July. The Wolbachia has the capability to prevent the dengue virus from replicating itself in the mosquito.
Deputy Prime Minister Datuk Seri Dr Wan Azizah Wan Ismail said the plan is to have these infected mosquitoes spread the virus around as a way to stem the spread of dengue fever.
“We want to prevent fogging so we don’t kill these mosquitoes,” she told the press at the Parliament lobby today.
A trial run in 2017, when four million infected mosquitoes were released in five localities in Shah Alam and Keramat, resulted in a 60% to 70% reduction in the incidence of dengue fever.
This time, the mosquitoes will be released in eight areas in Selangor and two in Kuala Lumpur.
It costs 50 sen to infect one mosquito with the Wolbachia virus, down from RM1 previously. The technology was imported from Australia.
Wan Azizah said the effort was necessary in view of the high incidence of dengue cases and deaths nationwide. In just the first three months of this year, the number of cases has risen by 146.3% and the number of deaths is up 84.4%, compared with the same period last year.
She also revealed that the use of artificial intelligence to predict where there will be a spike in the incidence of aedes mosquitoes and dengue cases is being considered.

/theSUN 02-04-2019

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Rare Diseases - Awareness and Funding Needed



In Malaysia, there is no official registry for rare diseases resulting in the absence of data as there is no tracking of the patients.

According to Rare Disease Malaysia website there are at least 79 types of rare diseases found in Malaysia.

Although the number of patients of each disease is small, rare disease patients as a collective is common.

The Health Ministry has yet to set an official definition for rare disease, complicating the monitoring and regulation of the management of rare diseases.

The Malaysian Rare Disorders Society (MRDS) has, therefore, taken it upon themselves to classify rare disease as a disease that affects less than one in every 4,000 people of the general population.

Malaysia does not have a National Rare Disease Policy.

Last year, a letter jointly written by three doctors from Universiti Sains Malaysia and University Malaya Medical Centre revealed that only 60% of rare disease patients in Malaysia are receiving treatment due to a lack of treatment options or a long waiting list.

On Dec 17 last year, Deputy Health Minister Dr Lee Boon Chye had told the Dewan Negara that the ministry would be formulating a National Framework for Rare Diseases but did not provide a timeline.

Dr Lee said the framework would include the setting up of a governance committee and a rare disease data system to facilitate policymaking, programmes, strategy and intervention.

Treatment costs for rare diseases are exorbitant, said Sunway Medical Centre Clinical Genetics external consultant Prof Thong Meow Keong.

“Drugs to treat neurological conditions such as spinal muscular atrophy may cost up to RM2mil yearly. Bone marrow transplants can come up to RM400,000, while growth hormones, up to thousands a month,” said Prof Thong.

The medical fees for rare disease sufferers are often well beyond the patients’ and their caregivers’ means, giving rise to the need for funding.

Malaysia Lysosomal Diseases Association (MLDA) president Lee Yee Seng said most parents have no choice but to rely on government aid and public generosity.

Lee himself has two daughters, Wei Ling and Yen Ling, diagnosed with Pompe disease, caused by an accumulation of glycogen in the lysosome due to a deficiency of acid alpha-glucosidase, an enzyme that converts glycogen to glucose. ERT for both of them can come to RM2mil annually.
 
Lee feels very grateful for the RM16mil budget allocated by MOH this year to Hospital Kuala Lumpur (HKL) for patients with rare diseases, including those suffering from LSD. Together with Zakat Selangor and corporate sponsorships, 50 LSD patients have benefited from these funds.

On Lee’s wish list are two key items: that the government come up with laws so that those with rare diseases can get prompt medical attention, and for stakeholders to come forward with funding to ease the suffering of those afflicted.

There are 90 other LSD patients registered with MLDA. The association was founded in 2011 and since then, 10 patients have died caused by complications brought on by their disease. For now, there is an urgent need for seven LSD patients to receive ERT treatments.

/theSTAR 28-02-201 


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