Bryan Tan

How has the Malaysian Healthcare System changed after privatisation was introduced and the impacts of this on patient care.
Abstract: The report starts with an introduction into what the Malaysian Healthcare System is, and what it was before. It then goes into Part 1 of the project, which details the effects of privatisation on the healthcare system. It then briefly discusses the effects of financial state of the economy on the healthcare system. The data which is analysed is mainly from 19951999. Part 2 of the project is based on the more recent data on the healthcare system, which includes the long-term impacts of privatisation on patient care. Primary data that was collected via a questionnaire to find opinions of doctors is analysed. Part 2 uses similar statistical data as Part 1, but also includes aspects of the Maternal Mortality Rate and Infant Mortality Rate as measures for the quality of healthcare available. The information which is analysed is then be evaluated. The main conclusion to this is that the Patient Care has improved, however whether or not this is due to privatisation cannot be concluded so easily. More data is needed in order to ascertain a true relationship between privatisation and beneficial impacts on patient care. Introduction: In the past thirty years, the Malaysian healthcare system has changed, due to privatisation. The aim of this article is to see how the healthcare system has changed after privatisation was introduced, and point out the impacts of this on patient care. Privatisation was first introduced in 1983 by the then Prime Minister, Dr. Mahathir Mohamed. The policy of privatisation was then continued by subsequent prime ministers Abdullah Badawi and Najib Abdul Razak. The idea of privatisation was most likely introduced based on the efforts done by Prime Minister Margaret Thatcher, who introduced privatisation into the United Kingdom over the 1980s. (Phua, Homepage of Dr Phua Kai Lit, 2010) I got the idea of looking into the Malaysian Healthcare System when I personally experienced the differences in the quality of patient care in the public and private hospitals. During my work experiences I also noticed many trends. For instance, in the public hospitals there were long queues to see a doctor and to receive medication. It was also difficult to get an appointment or to change one. Whereas in the private hospitals, there were shorter queues to see a doctor, more specialists available to patients and easier to get and change appointments. From this, I then thought about how the quality of healthcare had changed when privatisation was introduced; and what the differences were between the public and private hospitals. I eventually found out that this scope was too broad, and as a result, decided to focus on the impacts on patient care. Therefore, as my main focus in this essay, I will compare statistics from subsequent years of privatisation, drawing conclusions about how the healthcare system has changed as a result of privatisation. All of this will come under Part 1 of the report, Changes of the Healthcare System after Privatisation. To show the impacts of privatisation on healthcare, I obtained statistical data for subsequent years after privatisation. I will discuss differences between the public and private hospitals. I had not been able to find statistical data during the years of privatisation (1982-1984). Instead, I will be analysing data from 1995-1999. This data includes the number of doctors to nurses (public and private), number of hospitals (public and private) and number of beds (public and private). This will enable me to spot different trends that 1

Bryan Tan are present, which would allow me to make conclusions on to the Malaysian Healthcare System. Statistics that I will use to compare the public and private sectors (as well as compare how privatisation has affected the healthcare system) are the number of doctors to nurses (public and private), number of doctors to population, number of hospitals (public and private) and number of beds (public and private). As a follow up to finding out how the healthcare system has changed, I will include a section about how recent patient care has been affected as a result of privatisation. This will therefore make up Part 2 of the report, Impacts of Privatisation on Patient Care. As there are many things that involve patient care, I have decided to only focus on specific areas, and exclude certain areas. Namely, I have chosen to exclude the pharmaceutical and nursing aspects in patient care, as there is not enough data that I could use to write about; and including these factors widens the scope of the project too much. Part 2 starts out with the primary data (in the form of open questionnaires) which was collected from doctors working in the private and public sector. This was done to ensure that the results were valid, as then the basis used will be similar. The cost of this approach is that the sample size was much smaller, as finding an appropriate sample was quite difficult, due to the low number of doctors willing to take part in the questionnaire. After the data is analysed, the information will be then compared to the secondary data (between the years of 20062009), to find out any similarities between the two sets of data. To measure patient care, I had originally planned to use a ratio between the number of patients to a specialist (as access to a specialist may allow for better patient care). However, in the census data that I collected from the Ministry Of Health (MOH), this data was not available. Instead, I decided to measure patient care in a different way; through the use of ratios, such as the Maternal Mortality Rate (MMR) 1 and the Infant Mortality Rate (IMR)2 (Demographic and Health Surveys)

Research:
Methodology: Part 1: I mainly used information from the internet, with (Phua, Homepage of Dr Phua Kai Lit, 2003) being a major contributor for secondary research. Along with this, I sourced information from The Coalition Against Privatisation. I also used various sources for definitions of terms, as well as financial information. For instance, definitions of privatisation and corporatisation were sourced, and the GDP of Malaysia was obtained during the years 1995-1999. My own calculations were performed on the data from Dr. Phua, namely the doctor: nurse ratio. Part 2: I used open-ended questionnaires to encourage participants to voice their views, to include what they think of healthcare in the public and private sector. The questionnaire was loosely structured around the differences between the healthcare system, with the questionnaire focusing on trying to make the participants distinguish between the private and public sector, focusing with what is different in both sectors. This then leads onto what participants think of patient care. The sample that was used was primarily chosen because of the participants choice of working in the different sectors. For instance, some of the participants in the questionnaire are working in the public sector, while others are working in the private sector. This allows the results to be balanced and provide a reliable
1 2

MMR Whether or not a mother dies while giving childbirth, per 1000 births. IMR - Whether a child dies under one year, per 1000 births. 2

Bryan Tan perspective that can be taken to compare, the views from the people in the public sector with the views from people in the private sector. However, the sample used in the questionnaire was quite small, as access to healthcare professionals are scarce. This is because of the lack of appropriate sources that were currently available to me. The questionnaire that I used as well as the answers that were received are located in the appendix. Information which was collated for secondary research can be then be analysed, and opinions gained. Secondary research from part two was mainly sourced from the Ministry of Healths website, with statistics such as number of doctors (public and private), number of nurses (public and private), number of hospitals (public and private) and number of beds (public and private). Other information which is sourced is the MMR, IMR and Gross Domestic Product.

Bryan Tan

Part 1: Changes of the Healthcare System after Privatisation

Before privatisation occurred, nearly the entire healthcare system was nationalised (completely controlled by the government), with the government subsidising the healthcare and pharmaceuticals for the citizens. Therefore, the government was providing nearly all healthcare services for the citizens. Public hospitals are funded by the government, and healthcare is virtually free (1 RM for checkups and medicine, 5 RM for specialist treatment)3 On the other hand, private hospitals are not free, with every service chargeable. Privatisation and corporatisation of the Malaysian Healthcare System was introduced by Dr. Mahathir Mohamed. At the time, he had just risen to power as the fourth Prime Minister, under UMNO (United Malay National Organisation), and one of the first acts he did as the new prime minister was to introduce the concept of privatisation and corporatisation. The reason Dr. Mahathir Mohamed introduced privatisation was most likely to reduce the burden of healthcare on the public sector. There were many reasons why hospitals were privatised. One of the biggest reasons is money there is no subsidising of treatment/medicine and the hospital can choose to charge exorbitant amounts to make profits if they so wish. Another reason is that the hospital is in control of what it wants to buy, which treatments to offer (for instance, which equipment is needed). The acts of privatisation and corportisation took place in the year of 1983, but mainly involved privatisation of healthcare. In the privatisation of healthcare, many government resources (in this case hospitals and resources which are managed by the Government) were moved to the private sector. To clarify this, it means that a private company would make all the decisions in the way the hospital is run, whether it is for profit or nonprofit. The hospital would also be responsible for what equipment and resources it decides to invest in. In this way, the government does not have to manage and control resources, and instead, can devote more time and resources to sectors of the economy that it still controls fully. A lesser form of privatisation is called corporatisation. Corporatisation involves allowing a private company to run a business, while the government still maintains control over it. The government still maintains control on other businesses which are entirely provided by the government. This allows the government to still change the direction of the business at their will, maintaining a degree of control over businesses that they wouldnt have if privatisation had occurred instead. For example, a hospital called Institut Jantung Negara (National Heart Institute) (IJN) has been recently corporatised, leading to the hospital conducting very complex surgeries and becoming renowned for their advanced treatment into cardiac care in Malaysia. Corporatisation ensures that the hospital is able maintain the latest equipment, while allowing the public to access the surgeries that it offers. IJN also contains a profit making area, in which civil servants still receive free treatment. However the costs of treatment/medicine are charged to the pension department instead. For example, when my grandfather (a former civil servant) was admitted to IJN he did not have to pay any money; however, the bill was charged instead to the pension department. The reason for this is because IJN has to make a profit; however civil servants get free healthcare therefore the pension department is charged instead. After privatisation, hospitals have better resources, shorter waiting queues and medicine which are not available in public hospitals. However, only people who could afford the full cost of treatment would be able to switch to the private hospitals.
3

1 GBP Approximately 4.85108 RM as of 2/9/11 on http://www.xe.com/ucc

4

Bryan Tan

Table 1 Government and Private Personnel Doctors, Nurses, Pharmacists. Govt Doctors 4412 1995 4614 1996 8235 1997 8555 1998 8723 1999 (Phua, Homepage of Dr Phua Kai Lit, 2003, p. 4) and authors calculations Graph 1 Total number of doctors, nurses and pharmacists between the years of 19951999.
30000

Private Doctors 5196 5582 6013 6461 6780

Total Number of Doctors 9608 10196 14248 15016 15503

Govt Nurses 13647 14614 16068 18134 20914

Private Nurses NA 5442 8477 5538 6322

Total Nurses 13647 20056 24545 23672 27236

Govt Pharma cists 353 402 399 363 401

Private Pharma cists 1184 1313 1347 1766 1917

Total Pharmacists 1537 1715 1746 2129 2318

25000

20000

15000

Doctors Nurses Pharmacists

10000

5000

0 1995 1996 1997 1998 1999

(Data from table 1)

Bryan Tan Above is a graph which displays information from table 1 the total number of doctors, nurses and pharmacists in 1995-1999. There is a significant increase of doctors between the years of 1996-1997. Before and after this, the increase of doctors is much less significant. On the other hand in nurses, there appears to be many more nurses compared to doctors. The number of nurses are fluctuating between 1995-1999, with a decrease being found in the year 1998. I am unable to explain this decrease in nurses between this year, due to lack of information available. The number of pharmacists remain relatively constant over 19951999, however, this information is not conclusive. Graph 2: The growth of healthcare personnel in their respective sectors (public and private)
25000 20000 Govt Doctors 15000 10000 5000 0 1995 1996 1997 1998 1999 Private Doctors Govt Nurses Private Nurses Govt Pharmacists Private Pharmacists

Above is a graph that displays information from table 1 above, showing doctors, nurses and pharmacists in both sectors. Even though my scope of patient care (later in the project) does not include nurses and pharmacists, I included them to get a bigger picture of how privatisation has changed the healthcare system. For government doctors, there is a gradual trend of increase of doctors between the years of 1995-1999. However, there is a noticeable increase between the years of 1996-1997. Presumably, this means that there was a higher demand of doctors in the year 1997, and as a result, more government doctors were needed. An alternate hypothesis to this could be that the Government recruited more doctors, and at the same time, less or no doctors left public hospitals. However, more data is needed for further conclusion. Unlike their counterparts in the public sector, the private doctors have a steady increase in numbers over the years 1995-1999, indicating a steady growth in demand for doctors. As I was not able to obtain statistical data for the population for Malaysia, for those years, it is inconclusive whether or not this data is due to increase of doctors moving to the private sector, or whether it is due to more patients moving to the private sector. There are also many more government nurses than any other professions between 19951999, as can be seen in the graph above. This might be because there has to be a larger number of nurses per doctor. There is a constant increase in the number of nurses. This shows that even after privatisation has been introduced, there is still a heavy demand in the public sector compared to the private sector. This correlates with the steady increase government doctors, and shows that the public sector is still in need of doctors and nurses. 6

Bryan Tan

The shape of the graph of private nurses is slightly confusing, as there is a spike of private nurses between the years of 1996-1997, and a sudden decrease of private nurses between the years of 1997-1998. Given the data, I am unable to determine the reason for this sudden surge. However, my best guess is that there were more nursing colleges which opened up thereby increasing the number of nurses available. The doctor: nurse ratio is shown below. An interesting fact is that the doctor: nurse ratio in the private sector is much lower compared to one in the public sector. The information is demonstrated in the table and graph below. The data below could be used to find out what differences there are between the public sector, and the private sector, and even could be used to draw different conclusions regarding how the two sectors have changed over the five years. Table 2: Ratio of Doctors to Nurses in public hospitals. Public Doctors/Public Nurses Ratio (Doctors: Nurses) Simplified Ratio (Doctors: Nurses) 1:3.09 1:3.17 1:1.95 1:2.12 1:2.40

1995 4412:13647 1996 4614:14614 1997 8235:16068 1998 8555:18134 1999 8723:20914 (Compiled from data given above in Table 1) Table 3: Ratio of Doctors to Nurses in private hospitals. Private Doctors/Private Nurses 1995 1996 1997 1998 1999 Ratio (Doctors: Nurses) 5196:N/A 5582:5442 6013:8477 6461:5538 6780:6322

Simplified Ratio (Doctors: Nurses) N/A 1:0.97 1:1.41 1:0.86 1:0.93

(Compiled from data given above in Table 1)

Bryan Tan Graph 3 A graph showing doctor: nurse ratios in both private and public sectors between the years 1995-1999.
3.5 3 2.5 2 1.5 1 0.5 0 1995 1996 1997 1998 1999

Public Private

There needs to be a satisfactory number of nurses for every doctor, as nurses are equally important in providing healthcare services to patients as well. In the public sector the doctor: nurse ratio seems to constantly change. Even though the data from Table 2 showed that there was a major increase of doctors between the years of 1996-1997, the ratio of doctors to nurses over the 5 years remained largely the same. As expected, between the years of 1996-1997, there was a sharp drop in the doctor: nurse ratio. This is reflected in the major boost of doctors between the years of 1996-1997, while the numbers of nurses did not increase significantly. This might have led to better healthcare, as there are more doctors, and as a result, a smaller doctor: nurse ratio. In the private sector, there seem to be a more stable doctor: nurse ratio. However, this demand suddenly dropped between the years of 1997-1998, with the doctor patient ratio being maintained at just below one doctor to one nurse. After 1998, there was a gradual increase in the doctor to nurse ratio, and remained slightly below one (1:0.93). This is interesting compared to the public sector, as the private sector has considerably less nurses to every doctor than compared to the public sector. From this, it can be inferred that the public sector is much more busy, with nurses stepping up to help run the hospital and administer medical care. On the other hand, in the private sector there are less nurses to each doctor, however this data is not conclusive, and therefore, no assumptions can be made from this. In the public pharamaceticual sector, there is a gradual increase of pharmacists, however, not as much as public and private doctors in the same years. This suggests that there is either a lower demand for pharmacists in the public sector, or that the larger public hospitals do not require as many pharmacists. Similarly in the private sector, there are a considerably lower number of pharmacists compared to doctors and nurses (in both sectors). Additional information that we can gather is that there are more pharmacists in the private sector than in the public sector. This indicates that there are more private pharmacists, even though the private sector handles fewer patients compared to the public sector. This is slightly confusing, as that 8

Bryan Tan means less pharmacists in the public sector have to prescribe more medication to a bigger sample base, whereas the private sector would prescribe less medication to a smaller base of patients. However, we cannot soundly conclude anything, due to lack of other information. Now, I will compare the number of hospitals in each sector, and compare the number of beds in each sector as well. For easier reading of the graphs, I have separated the data into two categories Hospitals and Beds. These will therefore be displayed on two different graphs. Table 4 Table showing the number of hospital beds and private beds available between the years of 1995-1999. Year Public Hospitals (MOH) 111 111 111 111 114 Public Beds (MOH Hospitals) 26896 27242 27226 27162 28163 Private Hospitals 184 215 215 211 208 Private Beds

1995 1996 1997 1998 1999

6492 8793 8793 8873 8981

(Phua, Homepage of Dr Phua Kai Lit, 2003, p. 4) Graph 4 A graph showing the number of hospitals available in public and private sectors between the years of 1995-1999.
250 200 150 100 50 0 1995 1996 1997 1998 1999

Public (MOH) Private Hospitals

Hospitals

In the relationship between public and private hospitals, it is clear that the number of private hospitals outnumber the number of public hospitals there. However, it is interesting to note that even though the number of private hospitals increased between 1995-1997, the number gradually decreased over the next two years, suggesting that there was decreased demand for private hospitals in these years. This could possibly mean that less 9

Bryan Tan people (in the time) could afford private healthcare, and therefore chose to use the public healthcare system (the data for the sudden increase of public hospitals in 1999 suggests that the public sector is trying to cope with increase of patients in the public sector). Another possible explanation for this is that private hospitals could have merged together. This could occur to help increase profits, by having larger economies of scale. Economies of scale refers to the reduction in costs of production (in the case of medicine treatment costs, cost of medicine etc) by increasing the size of the hospital. However, this is unlikely as most of the hospitals tend to be in separate locations, and might have monopoly over treatment of private healthcare in the area. The data below shows the Gross Domestic Product per capita (a financial measure of how well the country is doing). I have decided to use this information due to it being able to decide whether or not the assumption posted above (that the economy is weak between the years of 1998-1999) is valid. Table 5 Gross Domestic Product and Percentage Changes between the years of 19951999. Year Gross Domestic Product, Constant Prices 1995 9.83 1996 10.002 1997 7.323 1998 -7.359 1999 6.138 (Malaysia GDP - real growth rate - Economy, 2011) Percent Changes (%) 6.72 1.75 -26.78 -200.49 -183.41

The data which is shown above agrees with my hypothesis above, that between 1995-1999 there was a decrease in how well the country was doing, leading to more and more private hospitals being decreasing from 215-208 and the increase of public hospitals to help cope with the influx of patients moving from the private sector to the public sector. This might mean that there is a decrease in demand for private hospitals in these years, due to .The trend is most noticeable when there is a decrease in GDP from 1997 to 1998, a -200.49% percentage decrease, which saw the sudden increase of public hospitals in 1999 (presumably they were being built between 1997-1998).

10

Bryan Tan Graph 5 A graph showing the number of beds available in public and private sectors between the years of 1995-1999.
30000 25000 20000 15000 10000 5000 0 1995 1996 1997 1998 1999 Public Beds (MOH Hospitals) Private Beds

In the graph of hospital beds (between the public and private hospitals) there are a noticeable higher proportion of public beds than private beds. This follows the principle that a higher number of people seek treatment at public hospitals, in comparison to the private hospitals, as a greater proportion of the general public will not be able to afford private care/not want to spend extra money on healthcare. An alternate conclusion is that most (if not all) public hospitals are bigger than private hospitals, and provide more beds. There was a general increase of beds between the years 1995-1999. This links in with the assumption stated above- that there was an increase of patients in the public sector, due to a decreased GDP between 1997-1999. The number of private beds also increased, most dramatically between 1995-1996, however this remained steady between 1997-1999. This suggests that while the number of private hospitals decreased, the number of beds in the hospitals remained steady. Conclusion: From the data above, we could conclude that the privatisation of healthcare has had major effects on the public healthcare system. For instance, with the introduction of privatisation, there has been a major increase of private hospitals, due to the increase of patients wanting private healthcare (due to various reasons, such as waiting time, access to specialist treatment). However, this data is inconclusive, and needs more data in order for a sound conclusion to be made. There are less private nurses in the same years as compared to the public sector. However, in 1997, there was a peak, which indicates that healthcare services were required more in that year, compared to the year before and after. The ratio of doctors: nurses are substantially higher in the public sector compared to the private sector this suggests that doctors in the public hospital are more busy, and as a result, nurses help bear the workload of the doctors. There are also many more private hospitals in comparison to public hospitals. At the same time, the number of public beds were much higher than the private beds, suggesting that the public sector is still much bigger than the private sector. From this we can also conclude that the majority of the population still goes to the public sector compared to the private sector. 11

Bryan Tan The private and public sectors are still expanding, with there being many more doctors to patients in the private sector, compared to the public sector this suggests that doctors are seeing more patients than private doctors. There is increasing demand for the private sector (as the economy grows, more people will be able to afford private healthcare), with more hospitals opening up. However, in the years of 1995-1999, there was a recession, which might account for why the number of private hospitals decreased, and number of public hospitals increased. Both the public and private sectors appear to have grown, when looking at the data of the number of hospitals, beds, doctors and nurses. However, there is a lack of population data available which helps discern whether or not the privatisation of healthcare system has contributed to the overall healthcare system.

12

Bryan Tan

Part 2: Impacts of Privatisation on Patient Care.

The second section of the project starts with a definition of how I define patient care. In this case, patient care is care relating to the treatment of the patient including the hospital visits (outpatient and inpatient) as well as the availability of treatments to the patients. In addition, it covers the cost of treatment, and availability of different doctors to treat patients (specifically, specialist treatment). Opinions which were gathered in the questionnaire will be analyzed to find different trends. Subsequently, secondary data (census data from 2006-2009) will then be analysed to find different trends. From this, the impacts of privatisation on patient care in the public and private hospital can be summarized, using both primary and secondary data. Information beyond five years ago is scarce. Because of this, I have chosen to only include information that covers the years between 2006-2009 (due to the lack of recent published resources on the MOH website). The information between 2006-2009, which was analysed, is mainly focusing on patient care, additionally, the information will be compared briefly to Part 1 of the research (similar statistics are used for easier comparison between them). There were many different opinions that presented themselves in my questionnaire. In total, there were 10 people (all doctors), who are from both the public and private sector. I collected data from a wide range of doctors Medical Officers, General Practioners, Paediatric Doctors, Ophthalmologists and a dermatologist were included in my sample. Gathering this data was quite difficult, as the sample could only include doctors. However, a wide range of different types of doctors was chosen, as different specialists could have different opinions, especially since different doctors were in different sectors. For this reason, only 10 samples were obtained 5 from doctors working in the public sector, and 5 from doctors working in the private sector. There was a major limitation of sample due to difficulty in getting doctors from public hospitals, as many of the doctors will move from the public hospitals to the private hospitals. Answers about my questionnaire were varied, with many different opinions available. Questions that I feel are the most important are analysed below. The questionnaire that was used is designed to prompt the respondents to highlight differences between public and private hospitals, and whether or not privatisation has benefited the healthcare system. In question 5 (Are there any main differences between working in the public sector and the private sector?) one answer is predominant. This answer is that the private sector will generate more income, while the public sector is seen as stressful, but interesting. To clarify interesting, in this case it means that diseases which are rarer are more frequently seen in the public sector compared to the private sector. Question 6 asks for three reasons why the respondents like working in their sector. An answer for respondents working in public hospitals which came up more than once was that, it was satisfying, and that patients were able to receive more advanced treatment (due to the larger budget given by the Ministry of Health which allows for more expensive equipment to be bought. In comparison to the private hospitals which have to be privately funded through profits and investments). In the public sector, doctors also do not have to worry about over-charging patients, due to subsidisation by the Malaysian Government. This is important, as the doctors can then give as many treatments and consultations as necessary, without having to worry about cost, which might hinder the quality of patient care. 13

Bryan Tan Question 8 (Are there any differences in the quality of patient healthcare between the public and private that you can see?) contained very varied responses. For instance, answers included: Private Sector: Different participants gave responses from the perspective of the patient (i.e. shorter waiting time, faster appointments). Another doctor listed (from their point of view) that they see less patients, and therefore have more time for a more detailed examination. Public Sector: Long waiting lists, and lower quality of care in public sector. From this, we can conclude that length of waiting time and the amount of time given per patient is one of the most crucial factors determining the quality of patient care in the two different sectors. All but two people said in question 9 that the public healthcare system had improved since 5 years ago. Reasons for this were: better facilities, many more specialists available and new machines can be used for better treatment for healthcare. People who had said no to the question elaborated on their answer by saying that the public sector has limited resources, for a bigger demand in comparison to the private sector. Question 11 (What do you think are the benefits of working in the private sector?) has very similar responses, with most participants stating that working in the private sector gives a higher pay than others. Similarly, some participants stated that there were more flexible hours while working in the private sector. One private doctor said that he develops better rapport with patients something which probably allow him to become closer to his patients, and gain their trust, therefore affording patients better quality care In question 13 (Do you think the separation of the public and private sector increases the gap of quality healthcare between the rich and poor?), there was an equal split in answers, with 50% of participants stating that there is a bigger gap in quality of healthcare between the rich and the poor, while 50% said vice versa. This is interesting, as it provides a second alternative to the common opinion that the poor cannot have good quality of healthcare. One participants reason was: Dont think so, poor enjoy best healthcare in the world in terms of quality compared to the private sector. Perhaps this opinion helps explain why 50% of the participants said no to this answer. In conclusion of the primary data, although I found many different opinions, quite a few were very similar, which allowed me to get useful quantitative data. Some of the participants opinions were varied, but gave interesting answers which may be compared to with the secondary research below. Secondary data that was taken from MOHs website over five years will be compiled and then analysed. For easier comparison, similar data from Part 1 of the report will be analysed. In this case, the number of government doctors, private doctors, the ratio of doctors to patients, and the number of public beds to private beds will be compared. In addition, I will also be comparing the Maternal Mortality Rate (MMR) and the Infant Mortality Rate (IMR) as mentioned in the introduction, as well as the inclusion of a doctor: population ratio. This is used as a standard for measuring healthcare (Wikipedia, 2011), and will be evaluated to find out whether or not patient care has benefited due to privatisation.

14

Bryan Tan Table 6 Number of Government, Private and Nurses between the years of 2006-2009. Government Private Total Doctors Government Total Nurses Doctors Doctors Nurses Private Nurses 21937 47642 2006 13335 8602 34598 13044 23738 48916 2007 14298 9440 36150 12766 25102 54208 2008 15096 10006 38575 15633 30536 59375 2009 20192 10344 45060 14315 (Ministry of Health, 2010) (Ministry of Health, 2010) Table 7 Number of Hospitals (Public and Private) and number of beds (Public and Private). Number of MOH Hospitals 128 130 130 130 Number of Private Number of Public Number of Private Hospitals Beds Beds N/A 30969 N/A 195 32149 11291 209 33004 11689 209 33083 12216

Year 2006 2007 2008 2009 (Ministry of Health, 2010)

Note: In 2006, the data for private hospitals and private beds were given in the form Total number of private hospitals, maternity/nursing homes and Total number of beds in private hospitals, maternity/nursing homes. Due to this, it is impossible to determine only the number of only private hospitals and private beds in the year 2006. Table 8 Doctor: Population Ratio (Public and Private), Maternal Mortality Rate and Infant Mortality Rate. Doctor: Population Ratio (Private) 1:3097 1:2879 1:2752 1:2697

2006 2007 2008 2009

Doctor: Population Ratio (Public) 1:1998 1:1901 1:1824 1:1835

MMR (Per 1000 Births) 0.3 0.3 0.3 0.3

IMR (Per 1000 Births) 6.6 6.3 6.3 6

(Demographic and Health Surveys) (Authors Calculations *Doctor: Population Ratio+)

15

Bryan Tan Graph 6 A graph to show the total number of doctors and nurses between the years of 2006-2009.
70000 60000 50000 40000 30000 20000 10000 0 2006 2007 2008 2009 Total Doctors Total Nurses

The above information shows us that there is a gradual increase in doctors, whereas the total number of nurses seems to increase more. The increase in both doctors and nurses could be due to increased demand from both the public and private sector, with the number of patients needing to be treated increasing over the years 2006-2009. Graph 7: A graph to show the number of doctors (public and private) and number of nurses (public and private).
50000 45000 40000 35000 30000 25000 20000 15000 10000 5000 0 Government Doctors Private Doctors Government Private Nurses Nurses 2006 2007 2008 2009

In graph 7, there appears to be substantially more doctors and nurses compared to 10 years previously (1995-1999) on page 6. This is presumably due to a rising population which will mean that there has to be more doctors to treat a higher number of patients. Compounding this is the advancement of technology which allows for job openings (e.g. advancements in radiotherapy allows for more job openings for radiologists). This means that there will undoubtedly be an increase in doctors, which is reflected in graph 6. Unlike 10 years ago, there appear to be many more government doctors compared to private doctors. There is a 16

Bryan Tan spike of government doctors between the years 2008-2009, while there is no noticeable increase of private doctors. This can be explained using data on the GDP of Malaysia. This data is similar to the one refered to in Part 1 (Page 10), used to establish a link between the state of the healthcare system and the strength of the economy. Table 9 A table to show the GDP between the years of 2006-2009, and percent change. Gross domestic product, constant prices

Year

Percent Change 9.70% 10.79% -27.35% -136.41%

2006 5.849 2007 6.48 2008 4.708 2009 -1.714 (Malaysia GDP - real growth rate - Economy, 2011)

From Table 9, it is clear that the economy is not doing very well between the years 20082009 hence we can assume that less people can afford expensive private healthcare, so naturally, more patients would turn to the public sector for their treatment. This would in turn lead into the sharp increase of public doctors, and public nurses. This is reflected in Graph 7, where there is a sharp increase in numbers for both doctors or nurses, from 15096-20192 and 38575-45060 respectively. Numbers of private doctors seem to be gradually increasing, however the number of private nurses decreased between the years of 2008-2009 assuming that there was a recession, less people would be able to afford private healthcare, so less income would be used for salaries for nurses. This means that possibly less people would receive better quality healthcare, as there are less nurses to attend to them. Graph 8 A graph to show the number of hospitals (public and private) between the years of 2006-2009.
250 200 150 100 50 0 2006 2007 2008 2009

Number of MOH Hospitals Number of Private Hospitals

17

Bryan Tan Graph 8 shows the number of the two types of hospitals.. In the data, we can see that there is a slight increase of public hospitals, between 2006-2007. Apart from this, there are no more new public hospitals. One hypothesis for this might be due to the fact that government hospitals are generally bigger (due to the number of patients they have to treat) compared to private hospitals. This would also explain why there are a much higher number of private hospitals, and why the number of private hospitals are still increasing. This would affect patient care, as it means that healthcare is less avaliable for the poor (less locations where they can receive treatment). On the other hand, this means that there will be an abundance in locations for healthcare for people who receive private treatment. Graph 9 Number of beds (public and private) between the years of 2006-2009.
35000 30000 25000 20000 15000 10000 5000 0 2006 2007 2008 2009 Number of Public Beds Number of Private Beds

The above table shows the number of public beds avaliable, compared to the number of private beds avaliable. The data suggests that there is many more public beds compared to private beds, which makes sense, since the public sector has to service more patients than the private sector.. This supports my hypothesis in the paragraph above, since it makes sense that there would be less public hospitals which were each bigger, and vice versa for the private hospitals. This means that there will then be more beds/facilities which the poor (who cannot afford private treatment) can use. From this angle, there is a positive impact on patient care, for both sides. Concluding from this paragraph, there would be more patients who would go to their respective sectors (due to better treatments, faster waiting time).

18

Bryan Tan Graph 10 A graph to show the doctor: population ratio (public and private) between the years of 2006-2009.
3500 3000 2500 2000 1500 1000 500 0 2006 2007 2008 2009

Public Ratio Private Ratio

Graph 10 shows the data which is compiled from Table 8 above. The data presented above has a major setback it does not distinguish between patients who visited the public sector, and patients who visited the private sector. Instead, it only focuses on the whole population, and thus is a limitation of the research. However, from the data above, we can see in both the public and private sector, there is a decrease in doctor:population ratio. This can be perceived to be a good thing, as patients will have a shorter waiting time, with more doctors being avaliable to attend to them and will have better healthcare. However, the data does not indicate whether or not a better healthcare is for urban or rural people.

19

Bryan Tan Graph 11 A graph to show the Maternal Mortality Rate and Infant Mortality Rate between the years of 2006-2009.
7 6 5 4 3 2 1 0 2006 2007 2008 2009

MMR (Per 1000 Births) IMR (Per 1000 Births)

In the above graph, it is apparent that the maternal mortality rate (MMR) is much lower than the infant mortality rate (IMR). It is also apparent that the maternal mortality rate is stable over the four years, while the infant mortality rate is gradually decreasing over the four years. As stated before, both the maternal mortality rate and the infant mortality rate are used as factors for determining the current quality of the healthcare system. Because the infant mortality rate is decreasing constantly, it is safe to assume that the healthcare system is improving, and as a result, assumptions can be made that the quality of patient care is improving. However, the data that is presented cannot be relied heavily on, as the data is using the general population (not individual sector's number of patients, which would be much more accurate), as then we could evaluate whether only the private hospitals is lowering the MMR/IMR compared to the public hospitals. Table 10 A table to show the Maternal Mortality Rate, over increments of 5 years from 1990-2000.

Year
1990 1995 2000

Value 0.8 0.39 0.41

Change -51.25% -5.13%

Cumulative Change -51.25% -48.75%

(Index Mundi, 2007), (Authors Calculations) The above data shows the maternal mortality rate, with increments over 5 years. As of 2009, the MMR was 0.3, indicating that there still is a decrease in MMR. This suggests that patient care is improving, as there appears to be a decreasing MMR.

20

Bryan Tan Table 11 A table to show the Infant Mortality Rate, over increments of 5 years from 1990-2000.

Year
1990 1995 2000 2004

Value 16 13 11 10

Change -18.75% -15.38% -9.09%

Cumulative Change -18.75% -31.25% -37.50%

(Index Mundi, 2007) Comparing the same data for the IMR, we can see that the IMR is steadily dropping, As of 2009, the IMR was 6 per 1000 births, which is low. However, in comparsion to the rest of the world, Malaysia is still 52nd (with Singapore being first) (United Nations, Department of Economic and Social Affairs, 2011). This indicates that Malaysia still has a long way to go in relation to the quality of healthcare in the fact that Malaysia could greatly improve its IMR. By improving its IMR, the quality of patient care could be greatly improved. Conclusion: From the second section, we can conclude that: The introduction of privatisation has had a positive impact of patient care. We know this because: o The total number of public and private hospitals has increased, allowing for more beds and doctors, consequently allowing for more patients to be treated at the same time, or with a higher standard than before. The impact of the recession (2008-2009) appears to have a noticeable affect on the healthcare system, with the number of public doctors increasing, possibly due to the increased need at the public sector. This may affect patient care, with the public sector receiving lower quality healthcare (due to the surge in patients) while the private sector recieves higher quality healthcare (due to less patients being seen). There are many more private hospitals compared to public hospitals. This, along with the the number of beds in each respective sector allows us to come to the conclusion that even though there are less public hospitals, each public hospital will most likely be much bigger than most private hospitals. From this, we can assume that each public hospital will be able to provide more treatments. This would mean that the public health care system has benefited. Similarily, the private healthcare system has also benefited, since private hospitals are now much more accessible (due to increase in numbers). From this, we can conclude that patient care (in relation to access to hospitals) has improved.

21

Bryan Tan

Evaluation
Evaluation of Part 1: The research in Part 1 was not as planned, in the sense that research was meant to be taken from the years immediately before and after privatisation, analysed, and then concluded from. Unfortunately, the research data was not availiable. Because of this, I have decided to analyse the impact of privatisation differently, by using subsequent data after privatisation from the years 1995-1999. However, this is no subsitute to having data from 1982-1984 (Privatisation was introduced in the year 1983), so data from years before could be analysed and then conclusions could be made about how privatisation affected the healthcare system. The data in Table 1 (Private Nurses 1997) appears to be anomalous. This is because the value goes from 5442 to 8477 to 5538 between the years of 1996-1998 respectively. Another way Part 1 could be improved is if statistical data for the population of Malaysia over 1995-1999 was obtained. This would allow me to make more conclusions with regards to the data present. Evaluation of Part 2: The primary research which was gathered was quite lengthly, however, the sample used is small and only includes doctors. The doctors who were asked also had to be working in different hospitals (public or private). Because of this, the sample was very hard to find. The research questionnaire that was produced was designed in order to prompt the participants on whether or not they agreed with a specific opinion, as well as ask their opinions of what differences (and advantanges/disadvantages) they thought of both the public and private hospitals. To this end, I believe that this was sucessful, however, more elaboration is required for further analysis. To do this, questions should be slightly reworded. The responses that participants gave were also quite hard to analyse, since they were mostly qualitative data. Instead, some questions requiring a Likert scale could be produced, leading to easy analysis of data. The range of doctors which were asked also had to be working in different sectors (public or private). Consequently, the sample was furthermore limited. Because I am still a student, I do not have very many contacts in the medical field. Because of this, I could not obtain a very big sample, and instead had to settle on a sample of 10 people. The secondary data gathered is not fully accurate, and could be improved. For instance, as mentioned before, the doctor to population ratio is inaccurate, due to the population including both public and private patients. In order to produce more accurate conclusions, the data which is present has to include public patients and private patients. Unfortunately, this data isnt provided by the Ministry of Healh government website, and as such, most likely very hard to obtain. The IMR and MMR ratio data could also be improved. For instance, if data for the IMR and MMR was seperated into both the public and private sector, then more conclusions could be made about each sector, rather than making an conclusion about the general healthcare system improving. Another increasing problem in the healthcare system today is the movement of specialists from the public hospitals to the private hospitals (probably due to the much higher income avaliable in private hospitals ). However, the census data which is made avaliable by the Ministry of Health does not include information which seperates specialist from non-specialists, and thus, would be very hard to obtain. Owing to this, no conclusions could be made about whether or not the quality of public healthcare is suffering due to the lack of specialists in the public sector. Another fault with the research was concerning the number of hospitals, and the number of beds. For instance, if most of the hospitals are geographically grouped very close together, 22

Bryan Tan that would mean that only a small fraction of people would receive good healthcare, with the others (especially those living in rural areas) would fail to receive adequate patient care. To improve my research, I would have included a patient survey along with the primary research conducted on doctors. This will allow me to gain perspectives from both sides of the healthcare system. An article that talks about the Malaysian Healthcare System is of great interest. (Bernama, 2011). Its title (98pc of healthcare costs subsidised by government) indicates that the government is still bearing the brunt of the costs for public healthcare. It also states that patients only pay 1 RM for out patient clinics (with medicine), 5 RM for specialist vists and a maximum of 50 RM for a type of ward hospitalisation. With my findings, I find that privatisation has helped benefit the Malaysian Healthcare System by allowing for a greater access of medical services to patients, as well as allowing for more patients being seen in the same time. Therefore, I conclude that there has been a mostly positive impact on the healthcare system.

23

Bryan Tan

Appendix:
The questionnaire I used to gather primary research is shown below. Below that are the answers to each question, in table form. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Which medical profession are you in? How long have you been working in this medical profession? Are you currently in the public or private sector? How long have you worked in the sector stated above? Are there any main differences between working in the public sector and the private sector? Could you name three reasons why you like working in the respective sector? Do you believe that the healthcare system was better than it was five years ago? Are there any differences (which you can see) in the quality of patient healthcare between the public and private sector that you can see? Do you believe that the public healthcare system has improved for the better now, and could you specify a few reasons? What do you think are the benefits of working in public sector? What do you think are the benefits of working in the private sector? What are your feelings on the governments decision to change from mostly public sector to mostly private sector? Do you think the separation of the public and private sector increases the gap of quality of healthcare between the rich and poor? Do you think its fair that some people will be able to afford better quality healthcare purely because they may have more money than others? Please elaborate. (Spreadsheet will be attached when final report is compiled)

24

Bryan Tan

Bibliography
Phua, K. L. (2010). Homepage of Dr Phua Kai Lit. Retrieved Janurary 15, 2011, from Homepage of Dr Phua Kai Lit: http://phuakl.tripod.com/ Phua, K. L. (2003, March 8). Homepage of Dr Phua Kai Lit. Retrieved December 7, 2010, from Dr Phua Kai Lit: http://phuakl.tripod.com/ Demographic and Health Surveys. (n.d.). Maternal Mortality Overview. Retrieved July 19, 2011, from Demographic and Health Surveys: http://www.measuredhs.com/topics/mm/start.cfm Malaysia GDP - real growth rate - Economy. (2011, July 12). Retrieved July 21, 2011, from Index Mundi: http://www.indexmundi.com/malaysia/gdp_real_growth_rate.html Ministry of Health. (2010, March 12). Laman Web Rasmi Kementrian Kesihatan Malaysia. Retrieved March 15, 2011, from Ministry of Health: http://www.moh.gov.my/v/stats_si Ministry of Health. (2010). Population ('000) by age group, Malaysia, 1963-2010. Kuala Lumpur: Ministry of Health. Index Mundi. (2007, February 15). Maternal Mortality Ratio per 100,000 live births Malaysia. Retrieved August 11, 2011, from Index Mundi: http://www.indexmundi.com/malaysia/maternal-mortality-ratio-per-100,000-livebirths.html Index Mundi. (2007, February 15). Infant mortality rate (0-1 year) per 1,000 live births Malaysia. Retrieved August 11, 2011, from Index Mundi: http://www.indexmundi.com/malaysia/infant-mortality-rate-%280-1-year%29-per-1,000live-births.html United Nations, Department of Economic and Social Affairs. (2011, June 28). United Nations World Population Prospects: 2011 revision. Retrieved August 11, 2011, from United Nations: http://esa.un.org/unpd/wpp/ExcelData/DB01_Period_Indicators/WPP2010_DB1_F06_1_IMR_BOTH_SEXES.XLS Coalition Against Health Care Privatisation. (2007). Health Financing and Reform: Should We Be Concerned? Coalition Against Health Care Privatisation. Malaysia: Coalition Against Health Care Privatisation. Wikipedia. (2011, July 24). Maternal Death. Retrieved August 8, 2011, from Wikipedia: https://secure.wikimedia.org/wikipedia/en/wiki/Maternal_mortality_rate Bernama. (2011, September 3). 98pc of healthcare costs subsidised by government. New Straits Times , p. 3.

25