Measuring up against WHO Asia Pacific’s 4 key proposed indicators for financing universal coverage, Malaysia has performed credibly. This can be reflected through notable health outcomes in mortality and morbidity which are on par with developed countries [17
]. National vital statistics in 2009 revealed maternal mortality rate to be at 28.0 per 100,000 live births, infant mortality at 7.0 per 1,000 live births, and expected life expectancy to be 71.7 and 76.5 years for men and women respectively [18
]. These outcomes are to be achieved through a comprehensive primary healthcare infrastructure that consists of an extensive rural health service, a referral system that integrates primary care clinics as the gatekeeper to secondary and tertiary care services linking district, state, regional, and general hospitals, as well as heavy government subsidy on public healthcare service provision.
Nonetheless, in moving towards attaining and maintaining a comprehensive universal coverage, various aspects beyond the health financing component needs to be taken into account. Health financing is only but one component of the overall health system strengthening framework that functions inter-connectedly with other key parts to be truly effective in delivering universal coverage and improving health outcomes. Under the WHO framework for action for strengthening health systems, five other building blocks were identified including health workforce, health information, medical products and technologies, leadership and governance, and service delivery; and all these blocks link and interact dynamically with health financing [24
In relation to health workforce, compensation of health workers comprises a large part of health expenditures, and various provider payment methods incorporated in financing mechanisms need to be effectively used to increase health workforce motivation. The public health sector in Malaysia has always been plagued with issues of low wages and overwhelming patient loads, which has spurred the brain drain of doctors and health workers to the private sector and also outmigration [25
]. Numerous schemes have been introduced to incentivize public health workers particularly doctors such as allowing locums, establishment of private wings, and direct salary increments but the difference with private sector remuneration benefits remains significant. In addition, unlike the public sector, there is no referral system in the private sector to screen out patients, leading to the underutilization of specialist expertise [27
]. The quality of housemanship training can also be affected by the medical brain drain due to the fact that all teaching hospitals in Malaysia are run by the public sector. Nonetheless, in the last few years, the government has made inroads in developing compensation strategies which could influence and improve the health workforce skill mix to deliver priority health services, deployment, retention and performance in underserved areas.
In terms of health information, data on health expenditure that is reliably disaggregated alongside epidemiological and health outcomes data is critical to support policies and technical reviews. The collation of health information in Malaysia has been vigorous and consistent both in terms of expenditure and vital health statistics. The establishment of the National Health Accounts unit has led to the systematic documentation and production of quality health expenditure data in accordance to international standards, and these data has been instrumental in supporting evidence-based policy making. While there are known shortcomings in the lack of data from the private healthcare sector, continuous efforts have also been made to approach private sector providers to provide key information such as admission rates and expenditure levels [2
]. A focused policy intervention on data sharing coupled with the development of a robust national database management system would be a viable strategy in the medium and long term to collate key missing data from the expanding private healthcare sector that would enable effective policy planning and optimization of healthcare resources.
In service delivery, health financing policies need to secure an agreed benefit package to address national health needs, especially those of the poor and including all types of care from preventive and promotive to curative and rehabilitative. While Malaysia has fared credibly in terms of curative care, there is a critical need to allocate more financing capacity to expand preventive care, in better managing escalating healthcare costs associated with the shifting of disease burden towards chronic non-communicable diseases (NCD). With NCDs dominating the top ten principal causes of death at government hospitals in 2010 [18
] and also the alarming increase in the prevalence of NCDs (i.e. diabetes, obesity, stroke) [28
], the effective management of chronic diseases at the population level could significantly affect the sustainability of the existing tax-based financing system. Allocative, technical and distributional efficiencies in health financing could contribute significantly to systems gains from better structure, organization and management, as well as cost-effectiveness of service delivery.
Data from the MNHA 2008 revealed that medicines and medical products constitute a significant share of out-of-pocket payments that contributed to driving the overall increase in total health expenditure. The acquisition of high-end medical equipment and new drugs should take into consideration the overall impact to the national healthcare expenditure, and purchasing decisions should be based on sound economic evaluation on population usage and cost effectiveness rather than market competition. The glut of medical equipment available in the private healthcare setting has been one of the factors that led to the increase in private health expenditure [29
] where competition promotes the duplication of expensive services and equipment [26
]. Issues of irrational drug use can be addressed through sound health financing policies in relation to drug procurement and distribution, alongside public education and clinical practice management. Health financing policies need to infuse the element of cost-effectiveness to better manage the purchasing of new medical supplies and equipment both in the private and public sector.
Lastly, health financing policy towards universal coverage is not isolated from the politics, pressure groups and lobbies at country level [30
]. Improving the health financing system would require the critical role of the government in interacting with stakeholders and guiding the overall public interest. Good governance and leadership are needed to ensure adequate public spending on health and maintain the focus on the attainment of universal coverage, which will need to be supported by legislative and regulatory frameworks that promote prepayment and risk pooling arrangements, and rationalize health spending both in the public and private sectors. Every year, the Malaysian Auditor-General report consistently highlighted discrepancies in the management of funds and resource management of the MOH both at the federal and state level [31
]. In this aspect, leadership is needed to make health care financing more accountable to the public, particularly in regards to inefficiencies and better utilisation of public funds and resources.