Globalization and National Autonomy: The Experience of Malaysia

8. Malaysia’s Healthcare Sector: Shifting Roles for Public and Private Provision by Joan M. Nelson

218 8 MALAYSIA’S฀HEALTHCARE฀฀ SECTOR Shifting฀Roles฀for฀ Public฀and฀Private฀Provision Joan฀M.฀Nelson Malaysia’s public health and medical services have a long record of broad coverage and effective low-cost provision. Until the 1990s, the sector generated little political controversy. It has also been largely free of ethnic divisions regarding objectives and policies. However, economic officials have long been concerned about the prospect of a growing fiscal burden of healthcare provision. Since the late 1980s, additional policy disputes have emerged as a reflection of Malaysia’s rapid economic growth and social transformation, the escalation of public demands and expectations for health care, and the growth of a dynamic corporate private healthcare sector. Malaysia is now struggling with the impact of private provision on the public system, emerging dualism, equity issues and fiscal concerns. The private healthcare sector has links to the international economy, but is not mainly driven by those links. Nonetheless, trends and dilemmas in the sector are powerfully, though indirectly, affected by globalization. THE฀EVOLUTION฀OF฀THE฀SYSTEM:฀A฀BRIEF฀OVERVIEW Malaysia’s public health and healthcare systems have served its citizens well. Health services, in combination with dramatic drops in poverty, 08฀GlobalNAn.indd฀฀฀218 7/24/08฀฀฀9:50:20฀AM MALAYSIA’S฀HEALTHCARE฀SECTOR฀ 219 rapid urbanization and rising education levels, have produced impressive improvements in health status. Table 8.1 shows dramatic drops in infant mortality and steady growth in life expectancy. However, data from the late 1980s show rural Malaysians, particularly those in poorer and more remote states and regions, lagging behind national averages, as did specific groups such as the Orang Asli, estate workers, and urban squatter settlement residents (Chee 1990, pp. 27–50). More recent interethnic data are difficult to find, but it is almost certain that substantial inequalities remain. From before independence, a central goal of the Malaysian public health sector was provision of basic services to the entire rural population. A network of rural primary care and midwife clinics was launched in the early 1950s, and expanded steadily. The clinics were staffed mainly with paramedical personnel and offered basic outpatient, preventive and promotional services. District and general hospitals comprised the higher levels of the system. More complicated cases were referred to these hospitals. As more and more Malaysians moved into the cities, general outpatient departments in urban hospitals provided a growing share of TABLE฀8.1 Trends฀in฀Malaysian฀Health฀Indicators,฀1970–2005 1970 1980 1990 2000 2005 Life expectancy All: male 61.6 66.4 68.9 70.0 70.6 (a) All: female 65.6 70.5 73.5 75.1 76.4 (a) bumiputera: male 60.8 66.5 69.0 69.2 bumiputera: female 62.7 68.9 72.4 73.5 Chinese: male 64.0 68.0 70.6 72.3 Chinese: female 71.3 74.0 76.3 78.0 Indian: male 59.0 62.1 64.4 65.5 Indian: female 61.3 67.0 70.4 74.2 Infant mortality 39.4 23.8 13.1 6.6 (a) 5.8 (a) Maternal mortality 1.4 0.6 0.2 0.3 (a) 0.3 (a) Sources: All data except where otherwise noted: Government of Malaysia, Malaysia Economic Statistics (Department of Statistics, 2000), pp. 137–39, Table 7.2, pp. 140–42, Table 7.3. Data with notation (a): Government of Malaysia, Economic Planning Unit, Prime Minister’s Department. Ninth Malaysia Plan 2006–2010, Table 20-6, p. 425. 08฀GlobalNAn.indd฀฀฀219 7/24/08฀฀฀9:50:20฀AM 220 JOAN M. NELSON primary services. In the early 1990s, comprehensive urban clinics separate from hospitals were introduced to handle outpatient care (Nik Rosnah 2005, p. 42). The system was generally judged to be highly cost-effective.1 As the economy and society were transformed, Malaysians’ needs and demands for health services evolved. Higher incomes, preventive health measures like immunization, and much improved public water and sanitation services reduced the relative importance of most nutritionrelated and many infectious diseases. Urbanization, industrialization, and the ageing of the population increased the incidence of chronic and degenerative diseases, as well as health problems related to life style such as smoking, drug use and, most recently, obesity. Recent largescale immigration has contributed to an upsurge in tuberculosis and the emergence of HIV/AIDs as a new challenge. The growing urban middle class expects higher standards...