CONCEPT PAPER

MINISTRY OF HEALTH

1Care for 1Malaysia:

RESTRUCTURING THE MALAYSIAN HEALTH SYSTEM

MINISTRY OF HEALTH MALAYSIA 11 AUGUST 2009

EXECUTIVE SUMMARY

CONCEPT PAPER FROM THE MINISTRY OF HEALTH

1Care for 1Malaysia:

RESTRUCTURING THE MALAYSIAN HEALTH SYSTEM
This paper is presented to introduce the concept of a national health system named 1Care, in line with the governments 1Malaysia model towards greater unity. Input and guidance of Economic Council members would help improve ideas in this concept paper. With the approval of the cabinet, MOH, with assistance from various partner agencies and stakeholders, will then undertake further systematic planning towards the development of a full blueprint for the 1Care national health system within a 2-year time frame. Phased implementation will be introduced with full evaluation and monitoring to ensure that objectives of the 1Care proposal are achieved. 2. Malaysias health care system is acknowledged internationally as a successful,

modern government-regulated health system that provides effective health services. Despite the accolades received, Malaysia, like many other countries, is apprehensive that the present system of health care delivery and financing may not be sustainable in the long term.

3.

The country faces several issues and challenges in order to put the population at

the forefront of health services and to increase the system performance and advance quality of care. These challenges include ensuring that services provided meet clients need; enhancing performance to improve equity of service; providing higher quality care; and overcoming limited and mismatched health care resources such as human resource, financial and physical infrastructure.

4.

Malaysias health care financing pattern mimics more that of lower and lower-

middle income countries while in reality we are an upper middle-income country striving for high wage earning status. It is now timely to restructure the system in order to align performance to the needs and expectation of the nation. 5. 1Care is the restructured national health system that is responsive and provides

choice of quality health care, ensuring universal coverage for the health care needs of the population through the spirit of solidarity and equity. 6. The proposed restructured Malaysian Health System will retain the existing

strengths of the current system. MOH will be streamlined to focus mainly on governance and stewardship, and specific community health services. The daily task of patient care will be devolved under an autonomous Malaysian Healthcare Delivery System with integration of public and private health care providers and services congruent with the 1Care concept. These changes will lead to more competition between the providers, higher quality and greater efficiency. The restructured system will be more responsive to population health needs and expectations through increased autonomy. Some functions will be placed under independent organisations owned by and accountable to the MOH. 7. The linchpin of the restructured health financing system is the contribution by

individuals and companies into a social health insurance (SHI) fund publicly managed on a not-for-profit basis. SHI premiums are estimated at 9.5% of household income, with contributions from the government, employer and employee. proportion of contributions are submitted for consideration. Two options in the The National Health

Financing Authority (NHFA) will safeguard the integrity of the system, its effectiveness to control the rate of health care cost increases and ensure the equitable financing and delivery of health services. 8. Overall spending for health will increase from 4.7% of GDP in 2007 to an

estimated 6.2% of GDP. Nevertheless, government subsidy on health care will reduce from an estimated 17.9% of TEH in 2007 to 15.6% in the proposed system through improved targeting of vulnerable population. Prepared by: Ministry of Health 6 August 2009
2

Contents
EXECUTIVE SUMMARY ............................................................................................................................1 CONCEPT PAPER FROM THE MINISTRY OF HEALTH .....................................................................4 OBJECTIVE ..................................................................................................................................................4 BACKGROUND ............................................................................................................................................4 Current Health System ............................................................................................................................4 Achievements ...........................................................................................................................................6 Governments Commitment ....................................................................................................................7 Challenges in the Current Malaysian Health System .........................................................................8 FEATURES OF THE PROPOSED RESTRUCTURED MODEL ........................................................17 FINANCING ARRANGEMENTS, COST & FINANCIAL IMPLICATIONS..........................................22 CAUTIONS AND CONCERNS ................................................................................................................28 BENEFITS ...................................................................................................................................................29 Benefits to the Nation ............................................................................................................................29 Benefits to the People ...........................................................................................................................30 Benefits to Health Care Providers .......................................................................................................31 CONCLUSION ............................................................................................................................................31 REFERENCES ...........................................................................................................................................32 ANNEXES ...................................................................................................................................................34

CONCEPT PAPER FROM THE MINISTRY OF HEALTH

1Care for 1Malaysia:

RESTRUCTURING THE MALAYSIAN HEALTH SYSTEM
OBJECTIVE
1. The objective of this concept paper is to propose a restructured national health system that will meet and sustain the future needs of the country. It introduces the concept of 1Care in line with YAB Prime Ministers vision of 1Malaysia. 1Care is the restructured national health system that is responsive and provides choice of quality health care, ensuring universal coverage for the health care needs of the population based on the spirit of solidarity and equity. 2. The purpose of tabling this concept paper is to seek input and comments from the

Economic Council members. It is also to get approval to develop a detailed blueprint for the restructured national health system.

BACKGROUND
Current Health System
3. Malaysia has a dichotomous health care system where comprehensive health

care is offered by a government-led public sector co-existing with a thriving private sector (Annex 1). The latter caters mainly for the personal care of individuals while the former provides for both personal care and public health services to ensure overall population health. There are many different financers and providers of health care serving various population sub-groups. Nevertheless, the Ministry of Health (MOH) remains the main provider and financer of health care in the country.

4.

There are glaring imbalances and mismatches between the public and private

sector in terms of resources and workloads. In 2008, although only 11% of primary care clinics are publicly owned, they handled 38% of total patient visits. While there are more hospitals in the private system, the reality is 78% of hospital beds remain within the public system, attending to 74% of admissions. Through concerted effort, 55% of doctors are now within the public system. Despite the greater workload for providers in the public system, more resources are spent through private financing (Figure 1).

Figure 1: Public-Private Sector Resources and Workload (2008)

Health clinics (with doctors) 802 Outpatient visits (m) No. of Hospitals 38.4 143

6371 62.65 209

Hospital Beds
Admissions Doctors (excl. Houseman) Health Expenditure (RM billion) (2007)

41249
2199310 12081 13.54 0% 20% 40% 60%

11689
754378 10006 16.68 80% 100%
10

Public

Private

Source: Health Informatics Centre (HIC)

5.

A national referral system has been established within the MOH to provide a

systematic assessment and treatment of patients, along the continuum of appropriate care. Patients access primary health care providers as the first point of contact and are referred up to higher levels as needed. Cases are returned to the primary care providers for follow-up, once close secondary or tertiary attention is no longer necessary. Despite some bypassing in the public sector, there is a pre-determined referral system to secondary or tertiary care, with primary care providers acting as gatekeepers (Annex 2). However, bypassing is rampant in the private sector where patients self-refer freely into

any level of care (Annex 3). The practice of doctor-hopping among certain patients is a matter of concern, as it does not promote prudent and desired health care practices.

Achievements
6. Malaysias health care system is acknowledged internationally as a successful, modern government-regulated health system that provides effective health services (Bloom G & Standing H, 2008). Malaysia has achieved notable successes in health status and the health sector including: reduction in morbidity and mortality and increasing lifespan of citizens; an equitable public health sector; universal access to a comprehensive government health sector; an effective safety net for catastrophic expenditure for chronic illnesses; minimal or no co-payment for services within the public system; health service focused on health promotion and disease prevention; and private sector responsive to market forces.

7.

Since Independence, Malaysia has achieved great improvement in health as

reflected by certain key health indicators. Life expectancy at birth for both genders has increased over the years, rising from 56 years for males and 58 for females in 1957 to 72 years for males and 76 years for females in 2006. (WHO, 2007). Infant mortality rate, which is a good indicator of overall health system performance, reduced drastically to levels comparable to developed countries. Nevertheless, Malaysias health indicators have plateaued over recent years, compared to other countries, some of whom invest more into their health systems (Figure 2).

Figure 2 : Selected Vital Statistics, Malaysia 1957-2006

Governments Commitment
8. The Government of Malaysia (GOM) has been committed, both conceptually and operationally, to progressively improve the health and quality of life of Malaysians. The Ministry of Health (MOH) strives to provide accessible, equitable and high quality health care to the population. Various public documents state the Governments role and

responsibility on health, notably the following:

Article 74(1) of the Federal Constitution stipulates that the Federal Government has the authority to legislate health matters. (GOM, 2002) Vision 2020 states (among others) the aim to ensure the Nation provides adequate access to health facilities (Mahathir M, 1991). Chapter F (Medical 1974) of the General Order for the Civil Services incorporates the proviso for free medical benefits for civil servants and dependants at public facilities only (GOM, 2006); The EPF Act 1991 initiated the Employees Provident Fund (EPF) as a compulsory savings scheme for non-pensionable employees and includes provision allowing withdrawal of a portion for medical treatment (GOM, 1991).
7

Malaysia is a signatory to the Universal Declaration of Human Rights (1948) (General Assembly, United Nations) wherein Article 25 states that Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, in circumstances beyond his control. Motherhood and childhood are entitled to special care and assistance. Since the Fifth Malaysia Plan, Malaysias 5-year Development Plans have included statements on cost sharing through health care financing mechanisms to provide wider choice and better quality of health services. Although efforts to study the sustainability and eventual introduction of a suitable financing scheme to replace the present one began in the 1980s, to date they have not lead to substantive action. Various reasons may have contributed to the inertia such as timing, political will, readiness of the government, peoples acceptance and enabling infrastructure to accommodate the change.

Challenges in the Current Malaysian Health System

9. Despite the accolades received, Malaysia, like many other countries, is

apprehensive that the present system of financing may not be sustainable in the long term, given the rapid rise in health care spending and the high out-of-pocket proportion of this spending. Furthermore, the country faces several issues and challenges in order to put the population at the forefront of health services and to increase the system performance and advance quality of care. The main challenges are: to ensure services provided meet clients need; to enhance greater performance; to enhance equity of overall service delivery; to ensure higher quality of care; and to overcome limited and mismatched health care resources such as human resource, financial and physical infrastructure.

Challenges in Serving the People Better 10. In striving to provide better services to the community, the public health care

system faces the constraints of higher consumer expectations, epidemiological and socio-demographic shifts towards an aging population and the changing attitude towards lifestyle, as well as a fairly rigid central administrative structure. The most common complaint received by the MOH is the long waiting time for services and medical procedures at all levels of the system. Greater expectations and demands are the

natural evolution of better education, higher income, and more access to information. Changing trends in socio-demography and disease patterns present a major challenge in the containment of health care cost (Figure 3 and 4).

Figure 3: Changing Demographic Trends

Source: Department of Statistics

Figure 4: Changing Disease Trends in Peninsular Malaysia (1970 and 2008)

11.

The elderly are living longer as evidenced by an increase in life expectancy. An

increase in the aged population is associated with an increase in the prevalence of ill health mainly chronic problems which require long term and continuous care. Elderly patients are more likely to be admitted with serious and life threatening conditions entailing high cost. The cost of health care will increase as the elderly population increases in the future.

Challenges in Achieving Greater Performance 12. While the population has benefited greatly from the publicly funded health system,

there are growing issues of inefficiency in the targeting of limited health funds. Government spending on public health services benefit even those who can afford to pay for care leading to leakages of public subsidy. Data from the National Health Morbidity Survey II (NHMS II, 1996) showed that among the richest quintile of the population, more than half (54%) still admit into public hospitals. It is necessary to encourage the rich to utilise public facilities because they provide the much needed voice to counter-check the system and maintain the critical patient mix. Nevertheless, leakages of public subsidy can be circumvented if the affluent are required to pay amounts commensurate with services rendered.
10

13.

The issue of limited appraisal and reward for performance in the public system still

needs to be addressed. Poor working conditions, lower remuneration and rewards coupled with heavy workload contributes to the continuous brain drain of experts and experienced staff from the public to the private sector and overseas. A less recognised problem is the high payment charged in the private sector even when care delivered does not meet acceptable standards. When the MOH tries to tackle such matters through legislation and enforcement, it is accused of conflicts of interest as MOH itself is both the regulator and provider of services.

Challenges in Improving Equity 14. In health care, both horizontal and vertical equity are relevant. Those with equal

need should receive equal care, while payment should be according to capacity to pay. Moreover, such payment should not be required at the time of use but through a regular prepayment mechanism. Regardless of the wide network of public and private sector facilities in Malaysia, its distribution is unbalanced. Private facilities are concentrated mainly in urban areas. Specialist services are available predominantly in larger towns. Hence, rural communities do not receive comparable services. This has contributed to the discrepancy of health outcomes between urban and rural population as shown in Table 1.

Table 1: Discrepancy in health outcomes by geographical location

Source: National Health and Morbidity Survey (NHMS) III, 2006

15.

Preferences for seeking care at various facilities are clearly income dependent
11

(Figure 5). When people earn more, they preferentially switch to seeking private health

care. As Malaysia strives towards becoming a high-wage earning country, the relevance of the public health system, as it exists now, is a major concern. Service charges at public health facilities (both primary and hospital care) are nominal and may even be waived on appeal. However, frequent media solicitations for financial assistance for health care indicate a weakness in the system. There is a need to increase the

responsiveness of the health care system and health providers to meet the needs and expectation of the population. Figure 5: Health care Utilisation by Income
government
100.0 90.0 80.0 70.0
Prevalence

private

100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0

Government

Private

60.0 50.0 40.0 30.0 20.0 10.0 0.0 Less than RM400 - RM700 - RM1000 - RM2000 - RM3000 - RM4000 - RM5000 & RM400 RM699 RM999 RM1999 RM2999 RM3999 RM4999 above

Less than RM400

RM400 RM699

RM700 RM999

RM1000 RM1999

RM2000 RM2999

RM3000 RM3999

RM4000 RM4999

RM5000 & above

Ambulator y care

Hospital care

Income Range

Source : NHMS III, 2006

16.

Since 2004, private spending on health overtook public spending (Figure 6). The

proportion of private sector expenditure has increased from 24% (Health Services Financing Study, 1985) to 55.2% (HIC, 2009). This pattern does not augur well for the health system because it has been shown that when majority of health care is privately funded, there is less control on health care inflation. Consequently, cost of health care in such situations will rise even faster (World Bank Institute,2007).

12

Figure 6: Public-Private Expenditure on Health, 1997-2007. Real RM Value (2007)

Source : MNHA (2007) &Public Private Figure 6: HIC (2009)
18,000

Expenditure on Health, 1997-2007 2.6 2.5 Real RM Value (2007) 2.3 2.4 2.4
2.1

2.1

2.1 2.1 2.2 1.9 1.9

16,682

1.6
16,000

1.7

1.8 1.6 1.7

2.0

1.5 1.5 1.5 1.6 1.6

14,360

1.0 13,546
Percentage (%)

14,000

13,034

RM million

12,000

12,067 11,558
11,740

0.0 11,542 10,271

-1.0

10,000 9,083 8,727 8,000 7,320 6,351 6,000 5,616

5,658 5,538 7,208 6,571 5,970 6,824

10,079

-2.0

5,806

-3.0

4,000

-4.0

1997

1998

1999

2000

2001
Year

2002

2003

2004

2005

2006

2007

PUBLIC (RM million) real RM2007 base

PRIVATE

Public as % GDP

Private as % GDP

28

17.

Of greater concern is the pattern of spending for health in Malaysia (Figure 7).

Malaysia is noted to have very high out-of-pocket spending. At the time of illness and vulnerability, people have to ensure that they have enough funds to seek care not only in the private system, but also in the public system where purchases of certain prescribed drugs, prostheses and equipment are not subsidised by government funds. This does not provide adequate risk protection from possible impoverishment as a result of seeking care during episodes of catastrophic illness such as cancers, renal failure and major cardiovascular conditions.

13

Figure 7: Ratio of Out-of-Pocket (OOP), Public & Private Expenditures

PERCENTAGES

COUNTRIES

Source : World Bank, 2005

18.

There is some risk pooling mechanism available in the private sector in the form

of voluntary private health insurance (PHI). These commercial for-profit organisations offer risk-rated insurance packages which are mainly affordable to healthy young financially independent people. Those who are in most need of financial security when seeking care such as the elderly who are not economically active and those with longterm chronic illnesses and pre-existing medical conditions, are unlikely to be accepted as insurers will deem them as very high risk. The PHI industry has grown tremendously in Malaysia in recent years. Unfortunately, to the health economist, this spells yet more bad news as PHI is another proven factor contributing to high health expenditure (World Bank Institute, 2007). 19. Malaysias financing patterns mimics more that of a lower or lower-middle income

country while in reality we are an upper middle-income country striving for high wage earning status. In these latter countries, social security infrastructure plays a significant role to garner private capacity into publicly managed fund-pooling mechanisms. In Malaysia, statutory bodies such as the Employee Provident Fund (EPF) and Social
14

Security Organisation (SOCSO) have only a minimal role in providing this social protection in health financing. Challenges in Quality of Care 20. The dichotomy of public and private provision has had a major impact on the

quality of care between the two sectors. Variations arise from the significant difference in infrastructure, such as facilities and equipment, as well as the clinical practice and competency of providers and ancillary staff. Such variations have significant impact, not just on perceived quality but more critically patient safety.

21.

At the same time, the unregulated growth of medical technology as well as its

ready assimilation into the private sector contributes not only to quality concerns but has also been proven to contribute to the rising cost of health care (Annex 4). The MOH Health Technology Assessment (HTA) section reports that of the 115 health technologies assessed from 2004 to mid 2009, only 33% were recommended for routine or selected use, 50% were not recommended while the balance should only be used in the research environment. Although the introduction of the Private Health care Facilities and Services Act (1998) has addressed some of these concerns, there is a need for a more concerted effort regarding the control and distribution of technology as an effective way to regulate the availability, use and equitable distribution of cost-effective technology to achieve higher quality of care.

22.

A challenge to the harmonisation of quality standards and practices across the

health system is the lack of information and data sharing. This is further compounded by low uptake of information communication technology (ICT) to assist clinical practice and evaluation as well management practises.

Challenges in Limited Health Care Resources 23. In considering resources for any sector, the main components are generally Despite efforts to

human resource, physical infrastructure and financial resource.

increase the health care provider numbers in Malaysia, the country still lacks a significant volume. The current doctor-population ratio of 1:1,255 is higher than the WHO
15

recommendation of 1:1000 (Oji, Utsumi & Uwaje, 2005). Moreover, skilled personnel are not necessarily distributed according to health needs of the nation (Annex 5). Private facilities in particular, responding to higher purchasing power, are concentrated in urban areas. 24. Given the volume of patients that utilise public hospitals, it is not surprising that

overcrowding is an issue that frustrates the governments efforts to provide more creature comfort to patients and visitors. MOH primary health care providers treat more patients with chronic illnesses compared to private general practitioners (GPs) who treat more healthy ill (ACG Project Team, 2007). For public sector specialists, about 70% of their patient workload consists of complex cases, compared to 25% for private sector specialists (Abu Bakar S. et. al. 1993). In such a stressful environment, it is perhaps not surprising that there are substantial unhappiness from both clients and staff in the public sector. 25. Although Malaysia is an upper middle income country, its level of health

expenditure mimics more that of a lower middle income country (Figure 8). The system is clearly under tremendous pressure. It is time to revamp the situation in order to align performance to the needs and expectation of the nation. It is time for business unusual. (Mohd. Ismail M., 2009) Figure 8: Total Expenditure on Health as percentage of GDP for Countries according to Income Level (2005)

16

FEATURES OF THE PROPOSED RESTRUCTURED MODEL

Main Objectives of Restructuring 26. Given the many challenges now facing the Malaysian health system, the

objectives of the proposed restructuring are manifold. The newly restructured system will have to be BETTER than what Malaysians already enjoy today, with enhancement of universal coverage in line with the 1Malaysia philosophy. The concept of 1Care ensures horizontal integration between the public and private sectors and vertical integration between the various levels of care within the health care delivery system. Through this integration, the development of a national health system will promote greater technical and allocative efficiency. 27. Health services will become more affordable through a publicly-managed

prepayment scheme, designed to ensure sustainability and appropriateness of the system to the needs of a progressive nation. The restructuring will undertake measures to improve equity in terms of access to better quality of care and financial risk protection. This includes effective safety nets for catastrophic spending due to illness in a responsive and caring health care system. 28. It is envisaged that increased personalised and community care will lead to

greater client satisfaction and health outcomes. A more conducive work environment will eventually lead to the reduction of the brain drain of highly skilled health care personnel from the country and from the public to the private sector. Features of the proposed restructured model 29. The proposed restructured Malaysian Health System will retain the existing

strengths of the current system. The role of the MOH will be more streamlined in 3 broad functions: Governance and stewardship Selected public health services Personal health care services devolved to the Malaysian Healthcare Delivery System (MHDS) Its main focus within the new public health functions would be the governance and
17

30.

stewardship of the national health system. The role of community health services and

the function of communicable disease control are critically important as witnessed by the current pandemic of H1N1 Influenza 2009 ravaging our country and indeed the world. This public good will remain protected and guaranteed as it remains within the MOH, but with a more specialised role. The MOH of the future will be managed as a tight ship of highly skilled senior experts, functioning cohesively in a matrix organisation. 31. The daily routine of patient care will be devolved under an autonomous Malaysian

Healthcare Delivery System (MHDS). The formation of MHDS will change the health care system in two major aspects: the separation of purchaser-provider functions from MOH, allowing the role of MOH in governing and financing the health system to be more effective and with fewer issues pertaining to conflict of interest; and the integration of public and private health care providers and services congruent with the 1Care concept. In the restructured system, Primary Health Care (PHC) will be the thrust of health

32.

care delivery in Malaysia. This change will result in better collaboration between public and private providers who now perform on equal footing, utilising similar care pathways and performance tools; thus leading to higher quality and efficiency. The MHDS will be more responsive to individual health needs and expectations through increased autonomy. To this end, some functions will be placed under independent organisations owned by and accountable to the MOH. These autonomous bodies, which are run by their own management board, will have the flexibility to engage and remunerate staff based on capability and performance. Staff and facility performance will also be the main criteria for service payments. Functional Relationship of the proposed restructured model 33. The schematic in Annex 6 highlights the functions of the restructured health

system. This paper is designed to introduce the broad skeletal concepts of 1Care and the restructured health system. The substance of the structure and detailed organisational arrangements will be developed in a blueprint for the restructured system when general approval to proceed is secured. New Public Health Functions
18

34.

The New Public Health Functions denoted in the chart includes policy and

regulations, public health services and any other services deemed necessary. The Policy & Regulation function includes those related to the following: Policy and Development - responsible to formulate and review all national level policies related to the health system planning including (but not confined to) standard setting, quality assurance, guidelines for good practice and adoption of cost-effective measures, infrastructure development, training needs, research, ethics, ICT support. These functions will apply to the various scope of health such as hospital care, disease control, family health, oral health, health promotion, pharmacy services, nutrition, engineering, and other areas of concern. Regulatory body specialised function mainly to formulate and review all legislations related to health care providers, health care practice and premises, marketing and use of medical equipment, pharmaceuticals and other medical and health products. Public Health, Medical Practice, Oral Health, Drug and Pharmacy, Medical Devices, Health Facilities, Food Safety, Traditional and Complementary Medicine, and Research. Emphasis will be placed on the clear delineation of function and responsibility for legislation and regulation so that oversight and enforcement will be effective and impartial to avoid conflicts of interest. Where appropriate, different aspects of enforcement may remain within the MOH or devolved to independent bodies. Monitoring and Evaluation to ensure restructuring of the health system will meet specific objectives. Performance of autonomous bodies will be monitored and evaluated. Quality and standards established by the Government will be implemented so that the people receive appropriate and satisfactory health services. Aspects such as health care provider assessment which encompass accreditation, credentialing and others will be given attention. Health quality control implementation will be carried out jointly with professional health bodies. In areas where there are legislation involving establishing of facilities and services, such as health care facilities and laboratories, assessment and monitoring in terms of zoning or issuance of certificate of needs will be required. There may be quota assessment before an approval is given.

35.

The Public Health Services function will focus on issues related to the

implementation of community based Public Health Services mainly focused on Communicable Disease Control, community level disaster management and others. Communicable Disease Control related services like Public Health Laboratory services
19

will be retained within the MOH. These services will be provided throughout the country within the existing public health network. Malaysian Healthcare Delivery System (MHDS) 36. The MHDS will be the implementing arm in the delivery of personal care. It

comprises of several Regional/State Authorities to address regional health needs. They are responsible for the strategic supervision of the following functions: developing plans for improving health services in their local area, making sure local health services are of a high quality and are performing well, increasing the capacity of local health services so they can provide more services, and making sure national priorities for example, programmes for improving cancer services are integrated into local health service plans. The MHDS does not raise its own funds. Funding of MHDS activities related

37.

directly to personal care will be obtained from the National Health Financing Agency (NHFA) based on pre-determined criteria set by the NHFA in collaboration with the MOH. Primary Health Care Trust (PHCT) 38. Primary Health Care Trust (PHCT) is an autonomous agency accountable to the

MHDS. It administers personal care as the key agency to purchase primary health care services and other levels of services for the region. They are responsible for providing personal care and preventive services. They oversee and purchase health care services from independent contractors (Primary Care Providers/Contractors), dentists and pharmacies. They also commission services from secondary or tertiary care providers such as hospital services, emergency services, etc.
Primary Health Care Providers (PHCP)

39.

Primary health care services will become the foundation of the health services

with strong focus on promotive-preventive care and early intervention. PHCP comprises medical practitioners and dentists, assisted by nurses and appropriate paramedical personnel, in public and private clinics operating individually or as registered groups to provide services under the financing scheme. The primary health care providers who are
20

independent contractors will function as family doctors and dentists, who are gatekeepers to secondary and tertiary care. Every individual in the population is registered with a PHCP. Financing of medical services is by capitation with case-mix adjustments (based on the communitys health profile). There are also additional incentives for achieving performance targets and as inducement for working in less desirable areas. The benefit package of services will be developed and other payment mechanisms apply for dental treatment and pharmaceutical prescriptions where patients will make some co-payments when receiving service. These co-payments are instituted to encourage prudent use of these services. Certain identified groups, such as the poor, will be exempted from these co-payments. Hospital Services 40. In the restructured system, patients will be referred by their PHCP to higher levels

of care, except in emergencies. There will be a regional network of autonomous public hospitals, based on distribution of expertise and sub-expertise available in every zone/state/district. The PHCT purchases hospital services from either the public network or private hospitals. The services provided by public hospitals, will be funded through a global budget based on case adjustments using Diagnostic Related Groups (DRG). Financing of the private hospitals services is through case-based payment. National Health Financing Authority (NHFA) 41. NHFA will be an autonomous statutory body, accountable to MOH. It will not be

privatised to safeguard the integrity of the system, its effectiveness to ultimately control the rate health care cost increases and ensure the equitable financing and delivery of health services to the Nation. It shall manage both the social health insurance and general taxation fund for personal health care as a single fund manager. Funds will be disbursed to the regional/state health authority based on specific and transparent formulas to cover the personal health care needs of that population. The NHFA will be accountable for the management of the overall health financing system in close collaboration with the MOH and MHDS. The main responsibilities of the NHFA include: Design Benefits Package together with MOH, MHDS and PHCT Negotiating with government for funding required to provide the agreed benefits package Monitor the fiscal performance of agencies within MHDS
21

Independent and Professional Bodies 42. Within the restructured health system, several existing independent and

professional bodies with specific technical functions will be strengthened while new ones may be established. These autonomous agencies are set up to ensure that the system will be more responsive to client needs. In some situations, they serve as regulatory functions for licensing and enforcement.

FINANCING ARRANGEMENTS, COST & FINANCIAL IMPLICATIONS

43. In the proposed system, current financing arrangements will also be restructured

to ensure better financial risk management, equity in financing of health care, greater efficiency of government subsidy for health care and accountability of work performance. The proposed financing scheme moves the current Malaysian financing picture, as described earlier (Figure 8), more into an upper middle to higher income country pattern. 44. Health care will continue to be financed through a combination of mechanisms but

with greater public financing, thus reversing the trend of private individual financing seen previously (Figure 6). Major components for health financing will now be publicly administered social health insurance (SHI) and general taxation, with much smaller components of private spending. Private spending may consist of out-of-pocket spending (OOP) to pay the minimal co-payments at point of seeking care e.g. for dispensing of drugs and dental treatment within the SHI benefits package, and for services not covered by SHI. Private spending will also include voluntary top-up private health insurance (PHI) and corporate spending for employees for coverage of high end care and other non-SHI covered items. 45. SHI contribution in the proposed system is mandatory with contributions for the

premiums raised from employer, employee and the government of Malaysia (GOM). The whole population of Malaysia has to subscribe to SHI with no avenue to opt-out from the system. This will ensure a high level of risk pooling and equity in financing for health
22

whereby the healthy will cross-subsidise the ill, the rich cross-subsidise the poor, and the economically productive cross-subsidise the dependant. SHI premiums are calculated as a percentage of income and shared by employer, employee and government funding. This model of nationally pooled financing will further enhance social unity and caring as per the 1Malaysia concept. To ensure greater equity and lower average premiums, SHI premiums are estimated through community risk-rating to cover all family members, and not individual risk-rating as in PHI. The latter will result in unacceptably high premiums for those with the greatest health care needs and yet have the lowest capacity to finance this need, and these are mainly the young and elderly. The estimates for financing in the restructured system are shown in Table 2 below. Table 2: Estimates for financing for the restructured system Estimated Annual Cost to Finance Malaysian Health System Expenditure for personal health care (PHC, specialist & inpatient care) As % of GDP Estimated Total Expenditure on Health with 5% administrative charge (Includes personal health care, public health, training, research, private insurance etc.) As % of GDP Per capita expenditure for personal health care Per capita expenditure for all health services SHI Premium for personal health care SHI Premium for average household (HH) SHI Premium as % of average household income (RM) 27.87b 3.9% 44.23b

6.2% 984.44 1,562.60 972.44 4,181.50 9.5%

46.

All estimates are made based on the assumption of population averages for

annual utilisation and cost. Primary health care visits are estimated for 6 annual visits per person. Specialist clinic visits are estimated on 0.78 utilisation rate and inpatient care on 0.09 utilisation rate (NHMS II). The Malaysian population is estimated as 28,306,700 (Department of Statistics, 2009). Average household size is 4.3 persons per household
23

(Department of Statistics, 2006). Unit cost estimates are RM40, RM317.39 and RM5088.16 for a primary care visit, a specialist visit and an inpatient episode respectively. A low 5% administration is estimated for the running of the system at steady state capitalising on economies of scale and prudent government management. 47. Funding contributions by employer and employee is a key feature of SHI as a

move towards greater social solidarity. There is no accepted gold standard on how to apportion government, employer and employee contributions to SHI premiums (Annex 7). We propose 2 options in funding contribution of either 2/3 employer and 1/3 employee participation as the preferred Option 1, or 50:50 contribution as Option 2. Option 1 is recommended given that majority of income tax collection for Malaysia is raised through corporate tax rather than personal income tax and companies are already spending substantial amounts privately to provide health care benefits to their employees. The 2 options are presented schematically in Figure 9. Nevertheless, these figures remain preliminary estimates and further analysis and estimates will be recalculated when the decision is taken to proceed further with the planning for restructuring.

Figure 9: Funding options for Employer-Employee contribution to SHI Premiums.

48.

With the proposed financial restructuring and the expansion of the social security

fund for health, beyond the current minimal health care spending through organisations such as Employee Provident Fund (EPF) and Social Security Organisation (SOCSO), public financing will increase from about 44% of total expenditures on health (TEH) to

24

76% of TEH, if the whole Malaysian population participates in the SHI programme. This is demonstrated in Figure 10.

Figure 10: Main Sources of Health Financing

49.

International experience has shown that countries with majority public funding for

health care is better able to control the rate of health care cost increases through greater financial management, economies-of-scale and the bargaining power of a monopsony not-for-profit organisation. Comparative analysis of the financing arrangements for both the current and the restructured health system is made in Annex 8. 50. The GOM remains committed to funding of health services in the restructured

system but with better targeting of beneficiary groups. This will reduce the use of precious government funds by those of higher income who can afford to fund their own health needs. Thus government subsidies for health care will be targeted to vulnerable groups. Through general taxation, the GOM will subsidise funding of primary health care services for the whole Malaysian population. At the same time, government will also subsidise SHI contributions for identified vulnerable population groups such as the poor,
25

disabled, and the elderly. As the largest employer in the country, the government will be expected to contribute to the insurance premiums of government pensioners, civil servants and five dependants. The GOM will also fund for various other components particularly items which are public goods and merit goods such as community health measures e.g. communicable disease control, health education, environmental health issues and in-service training for public health care providers. Funding for other items such as public infrastructure development and research will be through MOH budget. Estimates for these commitments are shown in Table 3.

Table 3: Estimates for Government Spending on Health in the Restructured System

51.

Therefore, in line with proposal to inject sufficient funds into the health system,

government spending for health will increase from 2.11% of GDP in 2007 to an estimated 2.85% of GDP (or from RM13.6billion to RM23.4billion in 2007 RM value). However, government subsidy on health care will reduce from an estimated 17.9% of TEH in 2007 to 15.6% in the proposed system through better targeting of vulnerable population. In absolute quantum, the reduction in subsidies of about 2.3% of TEH is almost RM1billion. 52. The linchpin of the restructured health financing system is the contribution of

private spending by individuals and companies into a national fund that is publicly
26

managed on a not-for-profit basis. This arrangement under the National Health Financing Authority (NHFA) will not be privatised to safeguard the integrity of the system and its effectiveness to ultimately control the rate of health care cost increases and ensure the equitable financing and delivery of health services to the Nation. 53. Funds to pay for SHI premiums may come directly from employer and employee

contributions as monthly salary deductions, and also through direct contribution by nonformal sector workforce (possibly at a reduced rate to be estimated later). Other possible sources of fund raising may include EPF dividends, EPF contributions and SOCSO funds. In line with other government plans to look at contributory pension schemes (pencen bercarum) for civil servants, it is conceivable that civil servants will also contribute towards their own SHI premiums as per private employers. If the programme is adopted, another possible source of funds may come from the Kumpulan Wang Amanah Pencen (KWAP). 54. PHI has been developing steadily in Malaysia providing some risk pooling for

health care amongst the higher income population. Current private spending for health of 56% of TEH in 2006 (41% OOP, 8% PHI and 7% corporate and other spending sources) will ultimately be reduced to 23% of TEH in the reformed system at steady state. Private spending will not disappear completely as this component allows for the continued development of PHI in specific niche areas as a voluntary top-up to the mandatory SHI programme. Individuals and corporations may also choose to fund other aspects of health services particularly the extra hotel-level comforts through some OOP payments or company expenses. 55. For catastrophic spending on conditions not covered in the SHI benefits package,

other existing sources of funding will be utilised. Such sources include the MOH Health Welfare Fund and the government grants given to specific non-governmental agencies to provide specific services such as the National Kidney Foundation, AIDS Foundation, National Heart Foundation and the National Cancer Council (MAKNA).

27

CAUTIONS AND CONCERNS

56. This paper is presented to introduce the concept of a national health system

termed 1Care in line with the governments 1Malaysia policies towards greater unity. In presenting this paper to the Economic Council (EC) it is expected that EC members will provide valuable input and guidance to improve the skeletal plans towards restructuring the Malaysian health system. 57. With the consensus of the Economic Council and approval of the cabinet, the

MOH, with assistance from various partner agencies and stakeholders, will then undertake further systematic planning towards the development of a full blueprint for the 1Care national health system within a 2-year time frame. Upon development, phased implementation of the programme will be introduced with full evaluation and monitoring to ensure that the objectives of the 1Care proposal are achieved. 58. Given the scale of the restructuring, it is imperative that change is managed

effectively at all levels of stakeholders. With further development of the blueprint many more deliberations with interested parties and stakeholders including the community will be undertaken to ensure that a solid and widely accepted proposal emerges, taking into consideration various aspects of concern. A realistic time frame for phased implementation is required to ensure that the requisite manpower, infrastructure and ICT needs and challenges are addressed. Appropriate training for health care personnel such as training in management of public providers and managers in preparation for greater autonomy has to be conducted. Effective change management will entail initial injection of investments particularly for the restructured public system in order to compete with the private sector on similar footing. 59. In preparation for expanding the 1Care concept expounded in this paper, a

comprehensive review of existing statues and documents will be undertaken to identify and streamline existing legislations and regulations on the governments role and responsibility. 60. It is understood that restructuring towards greater efficiency in health delivery may

require rationalisation of services in some regions and its development in others to also address equity issues. Payment mechanisms, incentives and market signals will lead to
28

change in the distribution of health facilities and the desired changes to ensure higher quality health care practices. 61. Planning and execution of the 1Care plan will occur over the longer term. Whilst

the current economic socio-political and global situation may be of concern to effect such changes in the short term, nevertheless it is expected that the EC will recognise that now is the ideal time (and indeed it is warranted) to prepare the necessary groundwork.

BENEFITS
Benefits to the Nation
62. The development of a national health system will strengthen national unity through a 2-prong process in which:social solidarity is fostered through SHI contribution specifically addressing marginalised segments of the population in accordance with the 1Malaysia effort. There are cross subsidies by the rich to the poor, the healthy to the sick, and the economically productive to dependants and enhancement of corporate social responsibility through employer contribution; and the 1Care concept emphasises the ethical delivery of health care, employing welfare and extra-welfare economic principles to tackle the obvious market failures of the health system for better efficiency and at the same time, addressing equity issues that troubles the system. This programme will stimulate the health care market through increased health

63.

care spending aligned with Malaysias upper middle income status. With enhanced public-private integration there will be increasing productivity and system

responsiveness. 64. The policy will capitalise on the liberalisation and globalisation of the health

care market and ensure that Malaysias health care system remains competitive with the ability to attract highly skilled medical personnel and support health care travel. At the same time, public funds and subsidies will not benefit foreigners at the expense of the Malaysian people.

29

65.

The restructured system reduces unnecessary dependence on government

fund by decreasing the leakage of government spending to those who can afford. This segment of society will contribute through SHI allowing better targeting of limited government subsidy. As mentioned previously, in 2007, government subsidy for

personal health care services was 17.9% of total expenditure on health (TEH). With the proposed restructuring, this will be reduced to 15.6% through better targeting of vulnerable groups, despite enhancement of services. 66. The proposed system will improve financial safety nets for lower and middle

income groups through better risk management. There is reduction of direct out-ofpocket spending (OOP) at point of seeking care by prepayment and coverage of the poor, disabled and elderly through general taxation. Through SHI, the paying population gains from the large pool of contributors. There will be lower insurance premium and wider benefits. There is assurance that no one is denied coverage due to any existing illnesses or has to pay substantial individually risk-rated premiums due to ill health. 67. Public management of majority of the health expenditure will ultimately contain

the rapid growth in health care cost and inflation. 1Care promotes greater efficiency through various means such as higher quality of care, more cost-effective measures, reducing duplication and increasing competition by attending to the inherent failures of health care market.

Benefits to the People

68. This proposal was developed with the ethos of serving Malaysians better. Through 1Care, people will get more access to both public and private providers in a move to bring about personalised care nearer to home. 69. At the point of physical and economic hardship during illness, individuals are not

faced with the concern of paying large sums or setting up deposits with the guarantee of minimal co-payments at the point of seeking care. With prepayment into the SHI scheme, there is assurance of access for vulnerable group, and addresses the demand and expectations of the middle-income segment of the Malaysian population. The restructured system has at its heart the pledge to improve quality of care delivered and client satisfaction.
30

70.

In the end the pursuit is for greater health outcomes for the community, thus

ensuring the means to higher work productivity and the ability to pursue individual life choices.

Benefits to Health Care Providers

71. The restructuring will bridge the gap between remuneration and workload among health workers in the public and private sectors. Eventually, the problem of public sector workers migrating to the private sector (brain drain) can be overcome. The restructuring optimises the existing health practitioners in the public and private sectors. The lack of health staff interested in serving less desirable areas can be addressed through the provision of specific incentives. Training and credentialing mechanisms will be

developed to ensure all health practitioners have the appropriate competency, in line with the care standards to be determined.

CONCLUSION
72. Malaysias health system has been recognised internationally as an excellent

system. However, current and future challenges will affect the sustainability and relevance of the system. Therefore, the restructuring of the countrys health system is critical. The proposed health system will have several clear advantages. Citizens, health practitioners and the government will obtain multiple add-on benefits. The 1Care concept is in tandem with the 1Malaysia philosophy to foster greater cohesiveness of the Malaysian population through the national health system. 73. The Economic Council is requested to consider and approve the proposed

concept of 1Care through Restructuring of the national health system to enable the Ministry of Health to further its blueprint development. Prepared by: Ministry of Health

7 August 2009
31

REFERENCES
Abu Bakar S, Wong SL, Jai-Mohan A. et. al., (1993) Utilisation of specialist medical manpower study 1992/93. Ministry of Health and Academy of Medicine, Malaysia. ACG Project Team (2007). Development of Teleprimary Care (TPC) Dataset Through Use of Johns Hopkins ACG (Adjusted Clinical Groups) in Malaysia (Draft). Development Division, Ministry of Health, Putrajaya. September 2007. Bloom G & Standing H (2008). Future Health Systems: Why Future? Why Now? Social Science & Medicine 66 (2008), 2067-2075. Retrieved on 31 July 2009 from the World Wide Web: http://www.futurehealthsystems.org/news/GHF/FHSflyer.pdf Department of Statistics, Malaysia (2006). Yearbook on Statistics, 2006. Percetakan Nasional Malaysia Berhad, 2006. Department of Statistics, Malaysia (2009). Population Statistics. Retrieved on 20 Julai 2009 from the World Wide Web: http://www.statistics.gov.my/eng/index.php?option=com_content&view=article&id=50:pop ulation&catid=38:kaystats&Itemid=11 EPF (2009). Employees Provident Fund- Treating Illnesses. Retrieved on 20 Julai 2009 from the World Wide Web: http://www.kwsp.gov.my/index.php?ch=p2life&pg=en_p2life_medical GOM (2002). Federal Constitution (As At 10th April 2002). International Law Book Series, Petaling Jaya. Article 74(1). GOM (2006). Perintah-Perintah Am dan Arahan Pentadbiran. International Law Book Series, Petaling Jaya. Bab F (Perubatan 1974) HIC (2009). Health Facts, 2008. Planning and Development Division, Ministry of Health, Putrajaya. May 2009. Institute for Public Health (1997). The Second National Health Morbidity Survey (NHMS II) 1996. Ministry of Health, Kuala Lumpur, 1997. Institute for Public Health (2008). The Third National Health Morbidity Survey (NHMS III) 2006. Ministry of Health, Kuala Lumpur, 2008. 32 Family Health

Jeffers, J. (1985). Health Services Financing Study, 1984-85. Westinghouse Health System. Asian Development Bank. Mahathir Mohamad (2001). The Way Forward: Vision 2020 Working paper presented at the Malaysian Business Council, Kuala Lumpur on 28 February 1991. Retrieved on 20 Julai 2009 from World Wide Web: http://www.wawasan2020.com/vision/ MNHA (2008), Malaysia National Health Accounts: Health Expenditure Report (1997-2006). Planning and Development Division, Putrajaya, 2008. Mohd. Ismail M., (2009). Healthcare business on the rise. Published in The Star on 4 July 2009. Retrieved on 28 July 2009 from the World Wide Web: http://thestar.com.my/columnists/story.asp?file=/2009/7/4/columnists/atyourservice/41324 33&sec=atyourservice NHI Bureau Taiwan (2004). National Health Insurance in Taiwan. Retrieved on 16 July 2009 from the World Wide Web: http://www.unicatt.it/CentriRicerca/Cerismas/Formazione/SGiminiano/2g_Taiwan.pdf Oji DE, Utsumi T & Uwaje C, (2005). International Centres of Excellence for e-Health in Africa with Global University System in Nigeria. E-Health International. Retrieved on 3 August 2009 from the World Wide Web: http://www.ehealthinternational.org/vol2num1/Vol2Num1 p23.pdf Rozita Halina H., (2008). Asia Pacific Region Country Health Financing. Institute for Health Systems Research, Malaysia. United Nations (1948). Universal Declaration of Human Rights. Article 25. Retrieved on 20 Julai 2009 from the World Wide Web: http://www.un.org/en/documents/udhr/index.shtml WHO (2007). Malaysia Country Health Information Profile. Retrieved on 4 August 2009 from World Wide Web: http://www.wpro.who.int/NR/rdonlyres/DB90A4E5-0963-4E00-B56CE09C2AE01ECC/0/19Malaysia07.pdf World Bank (2005). Health Expenditure Data. Retrieved on 15 May 2009 from the World Wide Web: http://www.who.int/entity/nha/country/Regional_ Averages_by_ WB_Income_group2005_En.xls World Bank Institute (2007). Basics of Health Economics. World Bank, Washington, 2007.

33

ANNEXES
ANNEX 1
Current Malaysian Health System

34

ANNEX 2

Access to Health Providers in Malaysia

MOH
SECONDARY/TERTIARY CARE

Other agencies & Private sector

PRIMARY HEALTH CARE

Health Clinics/Centres 1 : 20,000 population

GPs

Rural/Community Clinics 1 : 4,000 population

Orang Asli Facilities

Hospitals without Specialists

Medical Corps

Estate

Hospitals without Specialists

ANNEX 3

Access to Health Providers in Malaysia

MOH
SECONDARY/TERTIARY CARE

Other agencies & Private sector

By passing

PRIMARY HEALTH CARE

Health Clinics/Centres 1 : 20,000 population

GPs

Rural/Community Clinics 1 : 4,000 population

Orang Asli Facilities

Hospitals without Specialists

Medical Corps

Estate

35
Hospitals without Specialists

Others

Hospitals with Specialists

Private Hospitals

Hospitals with Subspecialty

University Hospitals

Others

Hospitals with Specialists

Private Hospitals

Hospitals with Subspecialty

University Hospitals

ANNEX 4
MEDICAL DEVICE AND EQUIPMENT IMPORTS IN MALAYSIA (2001-2007)

Source ??? Not Frost and Sullivan

36

ANNEX 5

Number of Clinics and Hospitals by State, June 2009

State Johore Kedah Kelantan Malacca Negeri Sembilan Pahang Penang Perak Perlis Selangor Terengganu Sabah Sarawak WP Kuala Lumpur & Putrajaya WP Labuan Total

Clinic MOH* 352 281 251 86 143 306 88 288 39 189 172 270 203 14 11 2729

Hospital Private MOH Private 805 336 185 278 261 222 483 619 32 1510 154 301 303 960 9 6458 11 9 9 3 6 10 6 14 1 10 6 22 20 2 1 130 28 11 3 4 7 8 20 13 0 41 1 3 9 30 0 178

* MOH : Health Clinics and Community Clinics only

37

Annex 6

Functional Relationship in the Restructured Health System

35

38

ANNEX 7
Country Year % GDP SHI funds (multiple/ single) % Contribution Employer Employee population (% income) covered

HIGH INCOME COUNTRIES

Australia Japan Korea 2005 2002 2007 9.7 8 5.6 Single (Medicare) Multiple Single payer (NHIC) Single Payer (Bureau for NHI) Multiple (17) Multiple (319) - 2003 National Insurance (Social Security) Multiple Nil SOCSO (Employment Injury & invalidity) Multiple Single Single Single public Multiple Multiple Single Multiple (Main - NHI fund) Single 39 All Residents 99% 97 1.5-2.5% 8 4-5% 4.55 (10% by govt.) 19.6 16 Nil 4 2 1.5-2.5% 4 2

Taiwan France Germany

2004 2008 2008

6.17 11.1 (2008) 10.7

99 100 99.8

2.7 (60%) 12.8 8

1.4 (30%) 6.8 8

United Kingdom Netherlands Hong Kong

2008 2008 2006

9.4 9.2 5.5 (2002)

100 98.5 Nil 7.2 Nil

(NI)11 4.8 Nil

(NI)12.8 2.4 Nil

MIDDLE INCOME COUNTRIES

Malaysia Indonesia Chile Philippines Costa Rica Thailand Mexico Nigeria

2007 2002 2004 2005 2003

4.7 2.8 6.1 3.3 7.1 4

16.8 10 86 73 88 Mixed 51% na

2.25 2.5 (ASKES) 7 2.5 15 4.5 (Govt. 1.5) 9.5 15

1.75 2 Nil 1.25 9.25 1.5 6.95 10

0.5 0.5 7 1.25 5.5 1.5 2.95 5

2002 2005

6.2 3.9

Tanzania Mongolia

2002 2002

8.7 4.3

na 77.3

6 4% (max)

3 2

3 2

Annex 8

Comparative data of selected countries on Total Expenditure on Health (TEH)

Source: WHO (2006)
2008 Figure ** Based on proposed system

GDP per capita US $

TEH per capita US $

TEH as % of GDP

Govt. HE (% of TEH)

Public HE (% of TEH)

Mid Mid High High Mid Mid Low Low Low High High

Malaysia

(MNHA)

7,221*
7,221* 38,443 19,115 3,869 5,440 1,051 2,254 895

245
445 2,936 973 98 201 37 26 24

4.3
6.16 7.6 5.9 3.5 7.3 6.0 2.1 4.5

44.2
46.1 14.6 11.4 56.0 33.6 17.0 37.0 41.9

44.6
76.9 81.3 53.0 63.9 84.8 25.7 46.6 46.6

Malaysia (New)** Japan Rep of Korea Thailand Colombia Vietnam Indonesia Kenya

Singapore
Taiwan Mexico

37,600
17,040 10,211

944
1561 474

3.5
6.17 6.4

26.5
9.0 17.3

31.9
66.5 45.5

Mid

40