• During the 1960s and early 1970s

• Largely rural population (74%)

• Low literacy (58%)

• Low health literacy

• Resulted in:

• Need and demand for access to hospital care by the rural population

• By the mid-1970s

• Rising demand for more complex secondary care, evidenced in the bypassing of district hospitals to seek care in larger hospitals able to provide better investigations and surgical services

• During the period

• Probably increased awareness of hospital services (no data)

• By the end of the period

• Improved availability of hospitals in rural areas (no data on access or utilisation at that time)

• High rates of maternal and infant mortality, vaccine-preventable diseases, malaria, TB, water- and soil-borne diseases, malnutrition

• Resulted in:

• Need for hospital care for treatment of more severe illness (TB, malaria, complications of childbirth)

• By the end of the period

• Deaths from serious illness and pregnancy-related causes declined

• Steady increase in GDP

• Rapid integrated rural development, including rural agriculture land development schemes (roads/bridges, schools, clinics, women’s mobilisation for income generation, basic literacy, nutrition and health)

• Resulted in:

• Improved transportation to hospitals

• Expanding network of hospitals

• Rapid expansion of primary and secondary schools

• Rising education level of school leavers

• Resulted in:

• Better-qualified candidates for the health workforce

• Probably increasing health literacy and empowerment of women, particularly for use of health services (no Malaysian data)

• Public sector:

• Rural MCH services and TB control programme formed close bidirectional links with hospitals, especially for maternal health, which helped to popularise safe childbirth, and for TB treatment.

• Private sector (NGOs):

• Private hospitals had links with TCM providers.

• Shortage of doctors and specialists dictated the types of services available at each type of hospital.

• Introduction of compulsory year of post-registration service in the public sector for all doctors to provide staff for more rural facilities.

• Nurses, midwives and medical assistants were the backbone of district-level hospitals.

• Demand for expanded health workforce to provide services in the expanding network of hospitals.

• Demand for health workforce willing and able to work in less developed states (e.g. East Coast states of Peninsular Malaysia).

• ‘Task shifting’ – the MoH granted authority to nurses and medical assistants to perform some tasks of doctors in remote locations where doctors were unavailable (e.g. anaesthesia, trauma care, some complications of childbirth).

• Financing

• Public sector: Provision of highly subsidised medical care funded by the government was almost free at point of delivery.

• Private sector: Payment was on a fee-for-service basis, being mostly out-of-pocket expenditure for patients and their families.

• Governance

• Laws and regulations under the MoH regulated the practice of the medical, nursing, midwifery, dental and pharmacy professions. The Boards also had oversight of recognition of qualifications.

• Very little information was available on hospital utilisation (only volume of admissions, childbirth, deaths and attendance at clinics).

• Resulted in:

• Inadequate data for management of hospital services.

• As a result:

• At federal level, the MoH began the process of strengthening hospital information systems and monitoring the quality of information.

• Standardised essential drug lists were implemented for different categories of public sector hospitals based on types of services available. This facilitated the implementation of clinical management protocols.

• Central procurement at federal level and improved supply logistics.

• Resulted in:

• Better availability (volume, continuous supply) of medical products in hospitals.

• Increased rural–urban migration

• By 1991, 51% of the population was urban

• Rapid rise in female literacy

• By 1997: 49% of primary school enrolment was female

• Resulted in:

• Rising literacy rate (72%)

• Improving health literacy

• Increased demand for allopathic medical care

• Improved access to basic STC services

• Increased demand for more sophisticated clinical care (investigation facilities, surgical services, specialist services)

• Outcome by the end of the period:

• Reduced disparities in access to care between geographic regions, especially between the West and East Coast states of Peninsular Malaysia

• Decline in major communicable diseases (CDs)

• Remaining burden from re-emerging (dengue, TB) and new CDs (HIV/AIDS)

• Rise in NCDs (cardiovascular, metabolic, neoplastic) and accidents

• Recognition of need for more sophisticated clinical care by policy-makers and politicians across the country

• Outcome by the end of the period:

• Improved quality of care in the public sector in terms of clinical outcomes, patient satisfaction and resource utilisation

• Budget constraints

• Macro policy directed towards:

  • Private sector as engine of growth

  • Improving efficiency to counter budget constraints

  • Nationwide quality-improvement initiatives in the public sector

  • Addressing imbalance between regions

  • Poverty-reduction programmes

• Resulted in initiatives to:

• Improve quality (clinical outcomes, patient satisfaction, resource utilisation)

• Outsource some hospital support services

• Begin the growth of private sector hospital and specialist services

• Better-qualified school levers were now demanding tertiary education.

• Tertiary education was expanded, including local production of doctors and various allied health professionals (see Chapter 8). This contributed to changing the profile of the health workforce in hospitals.

• Influence of other components of the health system

• on STC

• Influence of STC

• on other components of the health system

• Notification of CDs (dengue) improved through collaboration between the disease control programme and STC services.

• Support from STC to the PHC level was strengthened through the QAP, whereby senior specialists in state-level hospitals had to take responsibility for quality in their discipline in district hospitals and health centres (e.g. maternal health, paediatrics, surgery).

• Health workforce

• (see Chapter 8 for details)

• More doctors became available.

• There was brain drain of doctors and nurses from the public to the private sector.

• The competence and remuneration of nurses and hospital assistants (medical assistants) was upgraded.

• More specialised categories of allied health personnel were recruited or trained to support the growing number of specialist services.

• Management skills in public sector hospitals were upgraded.

• Increased demand for doctors, dentists, pharmacists and nurses

• Resulting in:

• Increased local production

• Increased financial support for foreign training of local candidates (doctors and dentists)

• Establishment of local training programmes for a wider range of allied health personnel

• Increased recognition of safety and quality issues in smaller private sector providers of inpatient care

• Increasing influence of clinical specialists in health policy and programme management

• Improved linkages with some public sector health programmes (disease control, e.g. dengue notification, clinical management protocol)

In 1985:

• % national budget allocated to health: 4.3%

• % GNP for health: 1.68%

• Public sector funded 75% of THE

• 13% of MoH budget spent on development

Demand for increasing share of the government budget for the health sector because of higher-cost personnel and high-cost technology

• Better quality and timeliness of hospital data facilitated

• Better allocation of resources (human, materials)

• Improved monitoring of performance (utilisation, clinical quality, patient satisfaction)

• Strengthened capacity for and production of health technology assessment contributed to rational acquisition of technology and products in the MoH network

• Monitoring of quality of care in hospitals strengthened the quality of data generated in hospitals, e.g. causes of death, ICD coding

• Strengthened capacity for clinical trials and management research in hospitals

• Improved communication with patients (health promotion, patient education)