CHAPTER 2
LITERATURE REVIEW
2.1 ACTIVE AND PASSIVE SUSPENSION SYSTEM
Rosheila Darus et al (2009) has explained the active and passive system for the full car and quarter car model to investigate the performance using LQR controller also to improve the comfort of the suspension. LQR technique gives higher amplitude on body displacement for active system but has faster settling time than passive system and also the wheel deflection amplitude is lower for active system compared to passive system. It was concluded that, it cannot perform in rough road disturbances especially for full car model but gives better ride comfort on quarter car active suspension system.

Abhijeet et al (2013) has developed a quarter car model to study the behaviour of passive and active suspension system. The response of passive system for step and two bump input was noted and also for the active system. It was concluded that using vibration absorber and additional dampers have improved the ride comfort slightly. The controlling element of the active suspension system is generally based on an actuator and the main problem faced was the power consumption of the actuator.
Phalke et al (2016) has explained the performance comparison of passive and semi active suspension system of a quarter car model for different velocities for half sine wave bump and then for different road profiles using MATLAB SIMULINK. A PID controller is developed which gives optimal and robust system by withstanding different road conditions and vehicle speeds to increase ride comfort. It is concluded that the settling time of semi active suspension system is very much reduced for all the bump inputs than the passive system using PID controller.

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2.2 CONTROLLER
Ervin Alvarez Sanchez et al (2013) has designed a sliding mode controller that allows avoid the induced road variations over the car body. The road perturbations profiles are differentiated with different amplitudes and frequencies. A bump and speed reducer are used as an input to check the suspension behaviour. It was concluded that the simulation results on MATLAB SIMULINK with the Runge Kutta numerical method for the numerical values of the quarter car suspension. The sprung mass estimator reaches the sprung mass value of 208 kg in a small time of about 0.01 seconds which allows using it in a new robust control scheme.

Ali J. et al (2008) has explained the controlling a quarter car hydraulic active suspension system using SMC techniques. The SMCs are able to reject the matched disturbance completely and reduce the effect of unmatched disturbance of the system. It was concluded that the displacement of car body is between -8 and +8 cm. The chattering related to the discontinuous controller and the nature of the systems and that can be reduced by using higher order SMC.

Chong Chee Soon et al (2017) has evaluate the performance improvement of the sliding mode controller integrated with PID controller. The control scheme is established from the derived dynamic equation which stability is proven through Lyapunov theorem. The PSO self-tuning algorithm that implemented in the PID sliding surface. It was concluded that the integration of PID, PSO and ZN gives the better result when compared to conventional ZN approach.

Rui Bai et al (2017) has designed the sliding mode controller to control the vibration of the active suspension system. A sinusoidal roadway is introduced as the input disturbance signal in the suspension system and by using the sliding mode control the vibration was suppressed within a small range with an active control. It was concluded that the implementation of SMC gives the better result on active control than the passive control.

2.3 AIR SPRING SUSPENSION SYSTEM
Abishek et al (2018) has developed a cost-effective quarter car test rig model that can generate the road profile like step, ramp, sinusoidal input. Based on the input signal given, the suspension behaviour can be studied and the corresponding sprung mass acceleration are noted with the help of accelerometer. Further, various controller like LQR, PID and fuzzy logic can be implemented to improve the vibration in the sprung mass. It was concluded that the future work to be do is to generate the ISO 8608 road profile on the test rig for different frequencies and compare it with the simulation result.
Gao Zepeng et al (2017) has explained the performance of the air spring for the electric vehicle with electric controlled air suspension and the relevant factors of air spring are analysed and the characteristics of the gasbag are simulated and verified in AMESim. The model of the electric vehicle body is analysed according to the law of dynamics and the fuzzy control theory is used to set up the electric vehicle body model in Simulink. In the case of unbalanced load, the effectiveness of the fuzzy controller is usued to simulate the phenomenon of “overshoot” in the system. It was concluded that the vibration is gradually slow down with fuzzy control and there is no obvious sense of shock and ride comfort improved.

Haider J. Abid et al (2015) has investigated the GENSIS air spring suspension system equivalence to a passive suspension system. The SIMULINK simulation together with the OptiY optimisation is used to obtain the air spring suspension model equivalent to passive suspension system, where the car body response difference from both systems with the same road profile inputs is used as the objective function for OptiY program. The parameters of air spring system such as initial pressure, volume of bag, length of surge pipe and volume of reservoir are obtained from optimization. The simulation results show that the air spring suspension equivalent system can produce responses very close to the passive suspension system.

Sathishkumar et al (2014) is dealing with modeling and evaluation of suspension system with a pneumatic actuator controlled by PID controller. A non-linear mathematical model of the dynamic suspension system with two degrees of freedom is developed. The controller is designed by setting proper gain values obtained by comparing three tuning methods namely Zeigler Nicolas and Optimal control. The time response of the air suspension system is contrasted with the passive suspension system due to the road disturbance modelled as a single bump input. It was concluded that for given road input the peak vehicle body displacement in optimal is lower than passive suspension system. The suspension travel of optimal PID system is better than passive when considering the peak overshoot, system response and settling time.

Fanbiao Bao et al (2011) explained the calculation and design of the vertical stiffness and frequency on the basis of mathematical model of air spring suspension system. This paper had SIMULINK computed and analyzed the response character according to road excitation spectrum as input. The simulation results were in accord with the driving condition well. The model can be used for suspension control system exploiter and ECU with vehicle model.

Shaohua wang et al (2010) explained the multi body simulation software to model a bus air suspension system. The parameters like vertical acceleration, working space, dynamic tire load was selected as a performance index to analyze the matching of suspension system. On the basis of comparison of simulation data, Suitable damping was selected after matching with air spring suspension in corresponding condition and the performance of air spring suspension system was improved.

M.Presthus (2002) explained the GENSYS model parameters without any experiment. The vertical parameters and horizontal parameters were obtained. Different parameters like thermodynamics and fluid dynamics constitutions were considered. The stiffness valves obtained from the simulation are close to the stiffness of the air spring.

2.4 ROAD PROFILE GENERATION
Agostinacchio et al (2013) has explained the theme of evaluating dynamic load increases that the vehicle transfers to the road pavement, due to the generation of vibration produced by surface irregularities. Method The study starts from the generation, according to the ISO 8608 Standard, of different road roughness profiles characterized by different damage levels. In particular, the first four classes provided by ISO 8608 were considered. Subsequently, the force exchanged between the pavement and three typologies of vehicles (car, bus and truck) has been assessed by implementing, in MATLAB, the Quarter Car Model characterized by a quarter vehicle mass and variable speed from 20 to 100 km/h.

Feng Tyan et al has reviewed the two of the most commonly adopted methods, namely shaping filter and sinusoidal approximation, for generating random road profiles. For the shaping filter they found that the time constant of the associated first order system transfer function is independent of the road profile grade. In the sinusoidal approximation, for long enough road profile, confirmed that the amplitude of each sinusoidal function is proportional to the square root of the related PSD, which is similar to the property of Fourier series coefficient.

Giuseppe Loprencipe et al (2017) has generated the equivalent artificial road profile for the real road profile. The real road profiles are significantly different from the artificial ones because of the non-stationary features of the first ones and the not full capability of the ISO 8608 equation to correctly describe the frequency content of the real road profile and also the international roughness index, frequency weighted vertical acceleration awz according to ISO 2631 and the dynamic load index are applied both on artificial and real road profiles, highlighted the different results obtained.

Hamet et al (2000) has addresses the influence of road texture profile on tire noise. A static approach based on evaluating the contact between two plane surfaces and dynamic approach is based on a rolling tire model. Attempts to correlate texture and noise on these pavements proved unsuccessful. It can be intuitively reckoned that tires with ‘aggressive’ tread patterns rolling on rather smooth road surfaces, will generate a tire road noise somewhat independently of the road texture profile, while tires with non ‘aggressive’ tread patterns rolling on highly textured roads, will generate a tire road noise almost independently of their tread patterns.

Chapter 2
Literature Review
2.1 Concerns Regarding Medical Tourism in Bangladesh
Bangladesh must find a way to capitalize on the potential of the emerging medical tourism sector. Unfortunately, lack of government initiative to encourage this industry is clear. The trend of Bangladeshi patients travelling abroad for medical services has, thus, led to a number of pressing concerns.
2.1.1 Perceived Quality
While other countries of the Southeast Asia region are profiting from medical tourism, Bangladesh not only lags behind but also loses patients to these countries. Patients are willing to go abroad for medical treatment because of the higher perceived quality of the treatment, despite the fact that the same treatment can be achieved more cost effectively within the country. As a result of the increased medical expenditure abroad, financial resources of the country are being regularly diverted out of the economy(HOPE medical tourism)
2.1.2 Marketing and Promotion
More health care facilities are being set up in Bangladesh and established facilities are increasing their capacities. Despite this, the rate of patients depending on foreign health care is increasing. Ironically, while Bangladeshi patients are seeking treatment in Apollo Hospitals in India and Sri Lanka, the Apollo Hospital in Dhaka is being underutilized and the hospital has had to lay off staff. Another reason for such failure could be faulty marketing. Marketing of the high quality of local hospitals is very weak, whereas foreign countries are establishing their reputation in this sector.

2.1.3 Information Dissemination
Another huge problem is that there is a lack of information about the current services provided by the local hospitals. Many patients are simply not aware of the competitively priced service packages available. For instance, procedures like coronary bypass surgeries have been very successful in a number of facilities like the National Heart Foundation and the Ibrahim Cardiac Hospital & Research Center. A range of more complex procedures like liver transplants are also available within the country. However, general ignorance due to lack of information dissemination has led to patients moving elsewhere.

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2.1.4 Trade and Supply of Health services
Health services are traded in various ways. Four dominant modes of exchange include: cross-border delivery, consumption abroad, commercial presence and movement of health personnel. There are mixed implications for such trade. On the bright side, it may trigger upgrading the health care exporter’s infrastructure, technological capacities, and health care standards. Also, for countries which import health services, medical tourism can be an important means of overcoming shortages of resources, particularly for specialized health services. However, trade in health services may also result in a dual market structure or aggravate such tendencies within the health care system. It can result in the creation of higher quality and expensive healthcare facilities which cater to the few wealthy locals as reflected by the recent number of designer hospitals that are being established in Dhaka, as well as lower quality facilities for the large majority
There are, however, numerous constraints to trade in health services. The three broad categories of constraints include: (a) restrictions on entry and terms of practice by foreign health service providers; (b) restrictions on foreign direct investment in the health sector and in related sectors; and (c) domestic infrastructural, regulatory, and capacity constraints. In each case, it is necessary to note whether these barriers are justified, whether they can be overcome, and whether alternative measures can be considered which would both facilitate trade in health services.

Health care service providers and planners in Bangladesh are often more concerned about the cost of health care rather than its quality. The majority of complaints of patients, however, are the behavior, conduct, and attitude of health care workers; yet nothing has been done to incorporate this into the training of doctors and nurses at the national level. Some factors influencing patients’ dissatisfaction in Bangladesh, derived from popular media, include:
Doctors recommending unnecessary medical tests for diagnosis of diseases
Irregular supply of drugs at the hospital premises
Irregular supervision of patients by care providers
Unavailability of specialists
Not providing correct treatment the first time by doctors
Long waiting time
Negative word-of-mouth that dissuades others from taking health care within the country
Not addressing the queries of patients
Lack of assurance of recovery
Low accessibility to the hospitals
Scarcity of doctors and nurses
Presence of extra payments (bribes) in every tier of the service
Low capacity and over priced services of quality hospitals
These issues have to be vigorously addressed before local, as well as foreign patients can be persuaded to consider medical tourism in Bangladesh.
This research will explore the reasons why Bangladeshi patients prefer to be treated abroad and what are the prospects of attracting medical tourist from neighboring countries while retaining our patients. The development of such a sector in our country will help in earning foreign currency and further strengthening the tourism sector. With a decrease in the number of patients travelling abroad, foreign currency losses from the economy can also be prevented.
2.2 Medical Tourism
John Connell (2006) mention medical tourism, where patients travel overseas for operations, has grown rapidly in the past decade, especially for cosmetic surgery. High costs and long waiting lists at home, new technology and skills in destination countries alongside reduced transport costs and Internet marketing have all played a role. Several Asian countries are dominant, but most countries have sought to enter the market. Conventional tourism has been a by-product of this growth, despite its tourist packaging, and overall benefits to the travel industry have been considerable. The rise of medical tourism emphasizes the privatization of health care, the growing dependence on technology, uneven access to health resources and the accelerated globalization of both health care and tourism.

Lee (2006) argues that Asian countries have a competitive advantage in the emerging healthcare industry. There are medical enterprises in countries such as India, Thailand, Singapore and Malaysia that have invested in attracting tourists for this specialist market.

Lee and Spisto (2007) argue that as an international business, medical tourism is not too different from the subcontracting or the off-shoring of services. With higher costs and expertise, in the future, medical tourism is likely to be the new global trend for providing medical services.

Tattara (2010) argues that Medical tourism in poor countries is strictly interlinked with the health privatization process and the ability to provide excellent treatment to some sectors of the population, not caring for the performance of the whole system.

Kanchanachitra et al. (2011) depict that vital human resources for health are available to meet the needs of the populations that they serve, migration management and retention strategies need to be integrated into ongoing efforts to strengthen health systems in Southeast Asia. There is also a need for improved dialogue between the health and trade sectors on how to balance economic opportunities associated with trade in health services with domestic health needs and equity issues.

Vijay (Access in the website 2011) the Indian tourism industry is now promoting medical tourism as a novel hope for the Indian economy. Five-star hospitals are mushrooming around the nation and major investments by big corporate players are expected. The privatization and ‘corporatization’ of health care has created medical tourism where people from rich nations travel to Third World countries to obtain medical care, experience and enjoy the tourism attractions and use other resources. It is a ‘magic lamp’ for those countries to attract overseas patients and earn foreign exchange.

Turner (2011) depicts that despite the rapid expansion of the medical tourism industry, few standards exist to ensure that these business organize high quality competent international health care. Standards should be established to ensure that clients of medical tourism companies make informed choices. Country of care needs to become an integral feature of cross-border care.

The first recorded instance of people travelling for medical treatment dates back thousands of years to when Greek pilgrims traveled from the eastern Mediterranean to a small area in the Saronic Gulf called Epidauria. This territory was the sanctuary of the healing god Asklepios. Spa towns and sanitaria were early forms of medical tourism. In 18th-century Europe patients visited spas because they were places with supposedly health-giving mineral waters, treating diseases from gout to liver disorders and bronchitis.

2.3 Medical tourism industry and its mechanisms
The patterns and tendencies in executing medical tourism over recent decades are vague and unidirectional. It might be alternative to regular tourists, which first pick the kind of holiday they want to have, regarding activities, time span, facilities and infrastructure – in short– their preferences. Then, they think of a country and region they can do that in and, at the end, they pick a hotel or resort they want to stay in, trying to utilize their stay and select the most cost-effective option. This could also be the mechanism in medical tourism: patients first decide not on a specific medical facility from the ones all over the world, but, once they recognize their medical needs and other preferences, they choose a country or region and then look for best medical facility within the chosen destination and at that last stage the price might be the differentiator. Therefore, it leaves the price as not-a-first-choice factor.

The sole use of services is only one part of the medical tourism industry. Other components of this complex mechanism shall not be forgotten or underestimated. As an industry, medical tourism consists of a wide scope of stakeholders, acknowledging mainly commercial, for-profit interests. Beneath are presented major participants of the industry.
Insurance Provider

Internet and Website Advertising
Internet diaries

Medical Tourists

Health Care Provider

Policies and Government

Events

Figure 2.1 Medical Tourism Industries and Its Mechanism
(Source: HOPE Publication, September 2015, Belgium)
2.4 Medical Tourism Challenges
The research has revealed that the medical tourism in a particular region has to face a large number of challenges. These challenges or barriers could cause difficulty to the growth of the industry. The major challenges in this field are (Shanmugam, 2013)
Availability of experts
Absence of a strong regulatory framework to control quacks
Absence of training in communication and interpersonal skills
Absence of innovativeness
Absence of international standard service and quality
Inadequacy of supporting staff
Absence of hygienic environment at the tourist destinations, hospitals, hotels, restaurants, etc.

Language acts as a barrier when people have insufficient knowledge of different languages
Other challenges include the inadequacy of supplementary services, which offers hospitality to the international customers at international standard. The lack of transparency and uniformity in prices of different Services and products causes ambiguity in a customer’s mind. As a result, a customer feels betrayed and loses trust on the Place. They share their experiences with other potential medical tourists. In this way a large number of medical tourists are deterred from visiting those places. Instead they seek other places for getting medical care. In addition, Absence of adequate networking in the distribution channels, specific standard, lack of coordination and organized efforts, inadequate infrastructure, water and power supply causes a big harm to the industry(Casken and Eissler, 2013).
2.5 The Main Features/Characteristics of Medical tourism Industry
From the above study, it was found that people target a particular destination for medical tourism because of the following factors
The advantage in costs, i.e. lower cost of a treatment at a particular country than other destinations.

The availability of expertise is better in the preferred country than other countries.

The efficiency and effectiveness of the expert treatment in a particular country.

The availability of technology, medical facilities and the time taken for the treatment in a particular destination.

The method used for treatment in a particular destination.

The convenience for the treatment in a particular destination.

Tourist attractions and the beauty of the place.

Availability of accommodations, transportation, entertainment, shopping and food outlets and ease of communication.

2.6 Drivers of Medical Tourism
K. Pollard introduced a “model of destination attractiveness”. The model covers the complex set of factors that determine patient’s ultimate decision where to pursue treatment abroad. It excludes technology and quality comparisons (as not contributing to being ultimate decision factors) and consists of seven key determinants.

Geographical proximity, travel time, ease and barriers in reaching the destination: Patients are not willing to take long, indirect flights from/to deserted airports, nor are they willingly going through complicated visa procedures.

Cultural proximity including language, religion, cuisine, customs and practices: Medical tourism seems to be influenced by familiarity and cultural similarity, for example former colonial connections (India-UK) and diasporas populations (coming back for treatment to a country people emigrated from).

Risk and reward: Medical tourists need to balance treatment outcomes against potential risks, considering safety, treatment guarantee, track records of particular medical services in destination countries etc.

Price: Not only the treatment costs count, but also travel, accommodation and insurance expenses. KMPG, on the other hand, lists geographical proximity and cultural similarities as prime reasons, later lower costs, better technology and wider treatment options, long waiting periods, tourism and vacation as factors that incentivize patients to follow treatment abroad.

Perceived quality: patients think that foreign healthcare services are of higher quality than in their national systems.

The waiting time: of the treatment in the target country relative to the waiting time in the home country is the second most important driver of selecting a cross-border provider of healthcare.

Trust in the healthcare: system in the target country and in particular the difference in trust in the target country healthcare system and the domestic healthcare system is the third most important driver of opting for a cross-border treatment.

Push and pull factors: The former includes high cost of out-of- pocket payment for procedure in home country, lack of insurance or underinsurance, long wait-times. The latter consist of quality of service, care and facilities, mutual language, vacation aspect, political climate, religious aspect.
McKinsey on the contrary, through conducted research, recognizes quality drivers as the major ones that influence patient’s decision on destination. They cover in order of importance: advanced technology, better quality, quicker access and at the very end – costs of care. The level of importance is presented in Figure 2

Figure 2.2 Medical tourism drivers
(Source: McKinsey Quarterly, Mapping the market for medical travel, 2008)
2.7 Intermediaries
The development of the medical tourism industry created a demand for travel and care-coordinating institutions, which in turn opened a niche for agencies and brokerages to start up businesses. Intermediaries often offer individually tailored packages, which include arrangement of treatment, recuperation, flight, accommodation, leisure etc. The ones located in country of origin are more patient-oriented, whereas the ones located in country of destination are more provider-oriented. Since brokers and agents do not hold any responsibility for patient’s well-being and satisfaction, it may be that they do not investigate the competences, qualifications, quality and scope of provided services of the health care facilities they send patients to. Nonetheless, it is obvious that the position of facilitators in medical tourism mechanism is strongly present, since travel arrangements are challenging for patients, as well as for clinics – reaching clients directly in foreign markets is a very costly promotion and marketing approach. Dr Jagyasi presented, through his research, that the majority of medical tourism professionals find the role of intermediaries significant. On the other hand, it is underlined that intermediaries should elaborate a kind of edge “to avoid the fate of traditional travel agencies”.

Additionally, the nature of patient-intermediary-provider relation induces a dysfunction within this triangle and within the referral fee system. In the situation, when the intermediary receives a commission from the provider per referral, it might be the case that the intermediary sends the medical tourist not necessarily to optimal and best for patient healthcare provider, but more likely to the one that pays the highest commission.

Going randomly through the list of medical tourism agencies, one can notice that some of the agents do not have websites or that the website links lead to nowhere, provide vague or hard to find information about their business and location or do not describe the scope of responsibility they bear as being the intermediary between the patient and healthcare provider. Hence, there seems to be need of regulating medical tourism facilitators, for example by licensing each one of them by the country they function in, therefore it will not allow anyone to be a “medical tourism agent”, as it is the case now.

2.8 Medical Tourism in Bangladesh
D’Essence (2004) suggested that most of the people undertake medical tourism to receive treatments for heart surgery/bypass surgery, overall cardiac care, cosmetic surgery, replacements of joints, Dental treatments, organ transplants or other concerns related to beauty or health. In addition, the author argued that the major players in the neighbor country, India are Apollo Hospitals, Escorts, Hinduja Hospital, Jaslok Hospital and Indraprastha Hospital. These hospitals provide excellent facilities to their customers. Additionally, Suleiman (2013) conducted a study that focused on the number of people treated in various countries. He submitted that more than one hundred thousand medical tourists have visited India in 2012 for cardiac care, joint replacement surgeries, Lasik treatments, etc. Around one hundred thirty thousand visited Jordan for fertility treatments or cardiac care and more than six hundred thousand patients travelled to Thailand for cosmetic surgery, organ transplant, dental treatment, etc. Moreover, eighty thousand people went to Malaysia for cosmetic surgery and beauty treatments. In addition, D’Essence (2004) suggested that people travelled to South Africa to enjoy the nature’s beauty and take help in cosmetic surgery, Lasik and dental treatments. Further, the author emphasized on the challenges that the medical tourism sector could face.

He argued that different countries put huge investments in different medical care practices. For example, The UK and the USA budget aim to promote and improve medical tourism in their respective countries. It is apparent from the fact that they invest a huge amount in million dollars for bone marrow transplant, open heart surgery, liver transplant, replacement of hips, knee surgery and cataract treatments. Developing nations, such as India and Thailand also focus on the above sectors for the growth of inbound medical tourism in their respective countries (D’Essence, 2004).

Moreover, Mamun and Andaleeb (2013) suggested that various services in hospitals need to be upgraded and improved to attract more medical tourists from abroad. The authorsargued that development of dedicated medical staff, hygienic environment, pick -up and drop facilities from airports, high quality diagnostic centres and pharmacies near hospitals, coordination of all appointments to avoid mismanagement and investigation of history of patients to know them better are of equal importance whilst serving international patients. Additionally, hotels, restaurants and accommodation facilities of international standard near hospitals increase the number of medical tourists in a country (Mamun and Andale, 2013). Muraina and Tommy (2012) conducted a study on the medical tourism sector in Bangladesh. The researchers argued that there are various factors for targeting a destination for medical tourism. Apart from the medical requirements, some people travel to see the beauty of nature, while others to see historical places, few people travel for their business purposes and others for cultural or spiritual gains.

However, Bangladesh is far behind in tourism. Although, the country has several tourist destinations, these destinations are yet to be improved to match the international standard.
Moreover, the different tourist attractions in the country have to be made safer for the local people and tourists (Ali, 2012). The transportation and accommodation facilities also need to be improved to attract the international community. Furthermore, Ma mun and Andaleeb (2013) evaluated the tourism sector of Bangladesh with the help of the 5-force model of Porter.
The authors suggested that the private sector and government sector initiative is very important for provision of excellent facilities in the country. There are a number of tourist destinations in the country, such as natural places and historical monuments.

For example, the Sundarbans forest, the sea beach in Cox’s Bazar, St. Martin’s Island, Tea Gardens of Srimongol, Lalbagh Fort, Tajhat Palace, etc. These places need to be improved to high standards to attract more people in the country. The research also stated that safety, security, accommodation and transportation are of great importance to create an international market. Additionally, good quality hospitals and a better health management system will itself retain the local people to receive medical benefits inside the country. Moreover, it will attract people from different countries to visit Bangladesh to receive medical care. This will generate a huge earning for the country.In addition, Afroz and Hasanuzzaman (2012) suggested that Bangladesh needs to be very fast in updating the adequate number of websites apart from the development of the basic medical facilities in the country. Moreover, the authors argued that Bangladeshis living abroad and various embassies of Bangladesh in the world should work together in a harmonious manner to enhance the number of visitors to the country. If this could be achieved, it will be of great help to the nation. Further, the local people tour operators could be of great advantage for the international medical tourists. Additionally, transparent procedures must be developed to enhance trust of the visitors because they will share their experience with others and this would increase the number of visitors in the country. Other entertainment facilities, such as shopping malls, local huts, cinema theatres, museums, parks, places of national importance, sea beaches, national forests, etc. and their approachability are also very significant to attract more people to Bangladesh (Ali, 2012). However, the bureaucratic structures, involvement of different ministries and agencies have made the system complicated. The places outside Dhaka give low rate of return on land investment, tourism infrastructure development, technological development and development of medical facilities. As a result, there is lack of investment in this sector of Bangladesh. In addition, the corruption and the instability in the political environment and legal environment have hampered the image of the country. Consequently, the private sector and foreign investors are discouraged to invest in the development and other plans in Bangladesh (Ali, 2012). As a result, most of the people from Bangladesh are travelling abroad to receive medical treatments and benefits (Muraina and Tommy, 2012). The topmost destinations across the world to get medical care are India, Thailand, Malaysia, Singapore, etc. (Awadzi and Panda, 2006)

CHAPTER 2 LITERATURE REVIEW
2.0 Introduction
The purpose of this study is to investigate the effect of health expenditure on GDP. This section contains a review of theoretical frameworks and empirical evidence about the effect of health expenditure on economic growth in different countries. According to World Health Organization (WHO), health does not only refer to the absence of disease or infirmity but also defined as a state of complete physical, mental and social well-being. Later in 1986, World Health Organization had further clarified the definition of health as “a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities”.
An online medical news website, Medical News Today has similar definition of health as World Health Organization in 1946. Besides physical well-being, Medical News Today stated that health also refers to a state of complete emotion. Medical News Today had classified health into two types which are physical health and mental health. Physical health can obtained by having regular exercise, balance nutrition and adequate rest in daily life. A healthy lifestyle can reduce the risk of being ill, injury and other health issue that helps to maintain physical fitness that leads to physical health. Besides physical health, mental health is also important because it reflects a person’s emotion, social, and psychological wellbeing. Mental health depends on the ability to enjoy life, feel safe and secure, adapt to adversity, achieve potential, and have positive thinking. Therefore, physical health and mental health are equally important for a human’s body to function at the peak performance.
According to Central Intelligence Agency, an independent government agency stated that health expenditure is the total expenditure that public sectors and private sectors spend on healthcare. Health expenditure is defined as the activities performed by institutions or individuals to promote, restore, or maintain health. The activities performed include the application of medical, paramedical or nursing knowledge and technology. Health Expenditure Report which published by Malaysia National Health Account from 1997 to 2014 stated that the healthcare service is provided by hospitals, providers of ambulatory health care, general health administration and insurance, provision and administration of public health programmes, institutions providing health related services, retail sale and other providers of medical goods, other industries such as rest of the Malaysian economy, rest of the world, nursing and residential care facilities. The services provided are curative care, health program administration and health insurance, prevention and public health services, capital formation of health care provider institutions, education and training of health personnel, medical goods dispensed to out-patients, ancillary services to health care, research and development in health, services of long-term nursing care, and all other health-related services.
According to the Chai, Whynes and Sach (2008)., fundamental principle of Malaysia health care system is the ability to pay that will not affect the health care especially in the event of sickness. Malaysia government understand that health represents human capital thus Malaysia government is concerned with the healthcare system and aimed to improve the health of nation. Malaysia practices a dual healthcare system which are public and private healthcare systems. Ministry of Health is the main public health provider in Malaysia which owned various type of health facilities to provide primary, secondary and tertiary care to citizens. In 2005, Ministry of Health has provided 122 hospitals, 6 special medical institutions, 809 health clinics, 1,919 rural clinics, 89 maternal and child health clinics, and 146 mobile clinics. Due to the subsidy from government, the primary health care services provided at clinics only charge RM1 for the diagnosis and medicine. Beside that, Malaysia government also provides high subsidy for secondary and tertiary health care service. For an example, 98% of health services cost provided by Ministry of Health in 2005 had subsidized by Malaysia government.
For the private healthcare system, the focus point of providers will be on the curative services. In 2004, there were 218 private hospitals, and about 5,000 private general practitioner clinics available in Malaysia. Healthcare services provided by private sector were expected to be high quality because they equipped the latest technology health care machines. However, the facilities of private sector are monitored and regulated by Malaysia government to ensure their facilities’ standard and quality services can fulfilled the requirement of National Quality Assurance Programme. Different from the public sector which only charged patient for RM1, user fees will be charged on patients according to treatment and services taken in private sector. As a comparison, charges in private health service will be higher compared to the public health service which is highly subsidised by government.
Therefore, World Health Organization has divided total health expenditures into two sources of funds which are public source and private source. All government agencies and the donation from public to government agencies are counted as the public source of health expenditure. Based on Health Expenditure, sources from public sector in Malaysia has been classified into 9 categories. The public sector sources are Ministry of Health, Ministry of Education, Social Security Organization, Ministry of Defence, Employee Provident Funds (EPF), State Government, local authorities, other federal agencies and state agencies which also including the statutory bodies. General taxes regardless direct or indirect taxes also collected by the Ministry of Finance to finance the public health care services. Moreover, Malaysia citizens can withdraw 30% from their Employee Provident Fund for health care expenditure and the rest of 70% are the saving for contributing his or her family in the old age. Besides, workers who injured during their working hours can get the medical benefits from Social Security Organization. Thus Employee Provident Fund and Social Security Organization are considered as the financial source of public health care.
On the other hand, private sector sources have been divided into 6 categories. The private sector sources come from private household out-of-pocket (OOP) expenditures, private insurance enterprises which is other than social insurance, all corporations which is other than health insurance, private managed care organizations and other similar entities and non-profit organisations serving households. Households use out-of-pocket (OOP) payment to purchase healthcare service such as surgery in hospital or purchase health service from third party such as non-government organization, insurance and parties other than government. Another private health care service finance source is private insurance. Different from the public health care service finance sources as stated above, citizens are voluntarily to purchase private insurance. The type of health insurance and level of coverage demand from citizens will lead to different premiums of insurance. Therefore, citizens purchase health insurance as a protection so they will have enough fund to purchase health care service when they are ill or for health improvement. Citizens can choose affordable health insurance plan based on their needs and income.
2.1 Theoretical Framework
Health status of a person is as human capital because it will directly affect on labour productivity and relative to economic growth. This is because healthy citizens and labour are more efficient and can lead to an increase of productivity of a nation. Higher productivity of nation is cause by healthier labour and it leads nation toward high income level. Statistical method have also shown that a productivity difference is the large part of the effect of health on rising earning (Todaro and Smith,2011). Bloom and Canning (2012) stated that healthy labour possess greater physical energy and dexterity lead the higher productivity of nation. The fact has shown a reverse causality between higher wages and better health. Due to the fact, healthier labour are more productive than sick labors, thus allow healthier labour to obtain better paying jobs and tend to spend more on health care to maintain their health. According to the researcher, there have 4 factor how healthier individuals affect the economics trend:
• They are more productive and earn higher income
• They spend more hours in the labour force compare to less healthy labour that take sick leave
• They spend higher income to invest in their own education and health, which will improve their productivity
• They save more in anticipation of a longer life after retirement
Therefore, healthier population will contribute more on productivity and lead to an increase in GDP level.
According to Konchitchk and Patatoukas (2014), gross domestic product (GDP) is defined as “the key summary statistic of economic activity and the most important variable on analyses of economic”. Gross domestic product has multifunction such as preparing federal budget, formulate monetary policy, indicator of economic activity, and key input for production, investment, and employment decisions. Gross domestic product can be calculated by income approach which total up the corporate profits, employee compensation, and taxes on production and imports. Health expenditure is one of the important factor contributing to the rise of GDP in Malaysia.
Relationship between HE and GDP
Healthcare expenditures are ordinarily hypothesized to be a function of real per capita gross domestic product (GDP). There are some reasons to suggest this could be a bilateral relationship, as it can be reasoned that population health is an input to the macroeconomic production function. There are some reasons how a bilateral relationship between healthcare expenditures and real per capita income could exist. First, by definition, health expenditure is a function of resources available (income or wealth). Second, a reverse causation, income as a function of health expenditures and it also has a theoretical basis due to the fact that the latter is a determinant of (i) human capital, (ii) labor supply and productivity. If health expenditure can be regarded as an investment in human capital, and given that human capital is an “engine” of growth, an increase in health expenditure will ultimately lead to higher income achievements. Similarly, rises in health expenditures make possible higher labour supply and productivity, which eventually must give way to a higher income.
Economics Growth Model
The theoretical structure of traditional neoclassical grow model from Lucas(1988), Romer (1990), and Solow(1956) have described two growth theories which are the exogenous and endogenous growth in economics growth model. According to the Solow model stated that the explicitly human capital is the key resource that affect the country’s economic growth. From his model, he explained that a useful expression for output per worker, where each stock (per worker) serves to a rise in production, thus the more production inflow to the market will lead to more stable economy growth. When rate of change of capital-labour ratio (?) equals to zero shows that capital-labour ratio (r) is constant. In the other word, expanding rate of capital stock and labour force are the same and we named it as n.

Figure above shows two curves which are nr and sF(r,1). nr is a function which crossing origin with slope n while sF(r,1) is another element from differential equation involving capital-labour ratio ? = sF(r,1) – nr. When nr = sF(r,1), ? = 0, and r* should never be established, capital and labour will grow in proportion. With the constant scale, real output will grow at the same rate as capital stock and labour force which is n, output per worker will be constant.
However, if r is larger than r*, which is to the right of intersection point, nr is larger than sF(r,1), r will decrease toward r*. If r smaller than r*, which is to the left of intersection point, nr is smaller sF(r,1), r will increase to r*. Thus r* as an equilibrium value is stable. Whether the initial value of r is larger or smaller than r*, system will also try to achieve balanced growth at natural rate. If initial value of capital stock is lower than equilibrium ratio, capital and output will grow faster than labour force. If initial value of capital stock is higher than equilibrium ratio, capital and output will grow slower than labour force. The growth of output is always in the middle level of labour and capital.
Lucas (1988) and Romer (1990) have determined that the endogenous growth model development as an alternative approach in 1980s. The model explained that the capital is unlimited to the physical capital and through health and education to enhance and developing labour’s knowledge, skills, abilities and experience.
Later, Lucas (1988) and Romer (1990) take into account human capital through education stock for the former with technology and research and development (R;D. Human capital is considered as a positive externality on capital productivity and its accumulation favourably influences economic growth and welfare of a community. In short, human capital is the stock of knowledge, competence, health, training, including creativity and other investments, embody the ability to perform labour tasks more productively. On the other hand, human capital formation refers to the process of acquiring and increasing the number of people who have the skills, good health, education and experience that are critical for economic development. Although human capital is multifaceted, many theories explicitly connect investment in human capital development to education and occult the other aspects, mainly stock and investment in health. However, health also plays an important role in human capital accumulation and is closely connected to education. For instance, a healthy population is easy to educate and the efficiency of people to produce human capital is also high. Besides, Lopez-Casasnovas et al. (2005) , also mentioned that “sustainable growth depend on increased human capital shocks due to a better education, a higher level of health and the new learning-application process.” According to Theodore (1961), young workers entering labour force have an advantage compared to old workers due to differences in productivity connected with human investment such as health condition and education. Labour who have higher education level, skilled and healthy can earn more than the labour who have lower education level, unskilled, and in poor health.
Relationship between HE and Income
There are many studies investigated the relationship between income and health expenditure that affects GDP growth. Income is the most important factor that responsible to explain the level of variation and also the growth of the health expenditure in Malaysia. Health expenditure is a luxury good with an income elasticity (Kleiman, 1974; Newhouse, 1997; Parkin et al., 1987; Gbesemete and Gerdtham, 1992; Gerdtham et al., 1992a,b). People with higher income tend to spend more in health care. Hence, this explained that income is a main contributing factor in describing the variation on health expenditure and the variation on health expenditure leads to changes in GDP.
Determinant of HE: Technological progress
According to Newhouse (1992), technological progress is one of the key factor to explain the variation on health expenditure that affects GDP. Baker and Wheeler (1998) and Weil (2007) proposed that several proxies has been used in the past studies, such as surgical methods and specific equipment, health care specific research and development expenditure (Okunad and Murthy, 2002); infant mortality and life expectancy at birth (Dreger, 2005); time index as a proxy for the impact of technology change (Gerdtham and Lothgren, 2000); time-specific intercepts (Di Matteo, 2004). According to Bodenheimer (2005), there is a major improvement in the health related to the technologies but in general it increases the health care cost. In addition, based on Lubitz (2005), a new low cost per patient per year technology to the health care system roses the spending on health and health care because there are more people being treated. Meanwhile, Newhouse (1992) said that, the medical care technology is having a fast improvement and spread easily into the health care system were majority responsible factor for the expenditure in health care grow up and thus GDP rises.
Determinant of HE: Medical technology
However, according to Serenson (2013), in between the medical technology and health expenditure there is a conflict and complicated relationship. The survival rates rose in health care technology while the cost that related to the health care had increased rapidly in ratio to GDP (Chandra and Skinner, 2012). Budget decision are more relevant for the expenditure growth. Furthermore, Tong (2009) has investigated that they used the co-integration and causality tests on health income nexus for Malaysia. But, there is an essential evidence saying that health expenditure and the real income for Malaysia remain controversial. Health care technology increased survival rates on one hand, but on the other hand it has rapidly increased the cost pertaining to health care as a ratio to GDP (Chandra and Skinner, 2012). Increased life expectancy is a measure of technological changes, which enhances labour force skills and efficiency. The more the skilled and technologically well-versed labour forces the more the efficiency which ultimately increase GDP per capita.
Determinant of HE: Aging population
Furthermore, past studies has broadly investigated the impact of aging population on health care spending growth (Zweifel et al., 1999; Hogan et al., 2001). According to United States Congressional Budget Office (2007), generally aging population expected to be the most important factor in health care system and health expenditure in the future. Based on Kinsella and He (2009) and U.S. Census Bureau (2014), by year 2020 Malaysia will become an ageing society where the population in Malaysia’s from age 65 years or older that will reach 7%. There is non-significant impact of aging population were found on total per capita health expenditure (H00ver et al., 2002; Tchoe and Nam, 2010). However, Breyer and Felder (2006), Schulz et al. (2004), Ogura and Jakovljevic (2014) and Khan et al. (2015) has identify that aging population contribute a factor that makes the health care cost accruing. In short run, there is a positive relationship between the aging and health expenditure (Bech et al., 2011). The total of health care spending and the health expenditure are elderly growing (Hakkinen et al., 2008; Mao an Xu, 2014).
However, according to Palangkaraya and Yong (2009) found that aging population is negatively related with aggregate health expenditure. In addition, the population growth are expected to decline further to one percent from 2020 to 2030 period. Based on MOH (2013), total fertility rate are represents the number of children that would be born to a woman if she were to live to the end of her childbearing years and bear children in accordance with current age-specific fertility rate. According to Leu (1987) and Cuyler (1988), the age structure of population was identified as a key indicator to explain changes in health expenditure across the nations. It explained that the population share are less than 15 years and above or up to 75 years of age estimated in the model while explaining the changes in the health expenditure per capita. Li Huang (2009) studied that the production function has a relationship between per capita real GDP growth and the physical capital, human capital and health investment.
Effect of Health Expenditure
In the multiplier theory effect, increased health expenditures generate an increase in the total expenditures in Gross Domestic Product (GDP) and aggregate demand in healthcare. In addition, the increased health expenditures leads to a rise in the employment in health sector due to the aggregate demand and supply significantly climb up. At the same time, the total income of the employed increases and help contributes to the total expenditures and increases aggregate demand. According to Serdar Kurt (2015) mentioned that “the health expenditures on total expenditures, aggregate demand, and total production are termed direct effect and which the effect is positive.”
3.0 Empirical Evidence
There are several studies have been done on the effect of health expenditure on GDP growth. One of the study by Aguyo-Rico and Iris (2010) examined the effect of health on economic growth for European, African, American, and Asian countries over a period 70s, 80s, and 90s using ordinary least square method of analysis and found that health capital has great effect on GPD growth, especially with a variable that captures all the determinants of health. Moreover, other studies such as Martins (2005), Strauss and Thomas (1998), Greiner (2005) and Agenor (2007) conducted on other countries shown that health expenditure is positively related to GDP. Furthermore, Bloom et al (2012) determined an aggregate economic growth production function as a function of labour, human capital and capital stock. The importance of results represent that healthy labour has positive effect on GDP growth.
Based on Zahra Mila Elmi and Somaye Sadeghi (2012) studies, health is a capital and investment on health can increase income and lead to the economics growth in overall. The healthier people the more productive because they can develop their skill and knowledge to enjoy the benefit in long term. Fuch (1996) specifies that 85% of the scholar in United States in the field of health economics approved that “technical change” that has been suggested by Newhouse has showed rapid growth of health care expenditure in the United States in past three decades. According to microeconomics views, if the income of an individual’s low (poor), the demand for the medical care also getting low. Since this happened, the marginal rate of return to invest in health for thru medical care is high. In this study, Baltagi and Moscone (2010) have reconsidered that the long-run economic relationship between health care expenditure and income using a panel of 20 OECD countries during 1971-2004. On top, they have studied the non-stationery and co-integration properties between health spending and income. The empirical procedure categories into two part which first is panel regression analysis and second is the quantile regression analysis. The estimation showed that the expenditure growth will stimulate economic growth. However, the expenditure growth will reduce due to the economic growth. The method this study using are collect data annually from World Bank which the period was 1990-2009. they used the co-integration test which has some testing methods, the panel v-statistic, panel p-statistic, panel PP-statistic, panel ADF statistic, group p-statistic, group PP-statistic and group ADF statistic. From the testing method, it shows that economic growth plays potential role to expand the health care spending in long-run. Furthermore, in long-run in developing countries the health spending increases due to engine of economic growth.
The economic performance of a country could conceivably be enhanced by improving health of the citizens. Based on the life expectancy-income relationship by Preston (1976), the extent to which additional resources should be invested in health is likely depend on the GDP of the country. The analysis of growth rates would be more reliable if the use of two GDP series led to similar results. First, we developed a framework for modelling the inter-relationships between GDP growth rates and explanatory variables by re-examining the life expectancy-income relationship. It argued that, while the effects of ASR are likely to taper off at relatively low GDP levels, a broader view of health entails focusing on human development, including the formation of human capital. Nutrition and learning are essential components of human development. Factors such as improved nutrition, better sanitation, innovations in medical technologies, and public health infrastructure have gradually increased the human life span. More generally, economic development depends on the level of skills acquired by the population and on capital formation. The former is influenced by child nutrition, educational infrastructure, and households’ resources, including parents’ physical health and cognitive attainment (e.g. Fogel, 1994, Scrimshaw, 1996, Bhargava, 1998a, 1999a). Capital accumulation depends on the savings rate that is also influenced by adult health.
On the basic of the model, we can consider that education and health play a vital role in terms of the quality of human capital. Therefore, expenditures on the education and health can improve the human capital quality level and it lead to the positive contribute to economic growth. From the study by Sorkin (1977) have examined the effect of health on economic growth, he mentioned that healthy people can contribute more production in the market and the deceased in birth rate have positive effect on the economic growth and GDP. On the other hand, Taban (2006) and Sunde (2009) also examined the relationship between economic growth and life expectancy at birth, from the fact the decrease in the birth rate can decline the human capital contribute to the economic growth and it can cause of sustainable loss growth. If the population of the country is small, the production level of the country will be limited. Besides, OECD have mentioned the decrease in mortality rate under 40 years old lead the increase growth in economics.
According to Sefa Awawoyi Churchill, Siew Ling Yew, Mehmet Ugur (2015) studies, they re-assess the growth effect of government education and the growth effect of government health expenditure. In this study, they found out the effect of government education expenditure on growth is positive where a negative growth effect observed on the government health expenditure. They obtain positive growth effect by combining the measure government expenditure on education and health. Grossman (1972) proven that an increase in health capital will reduce the time lost to illness and it allows more effective performance that will increase in productivity. It is supported by Strauss and Thomas (1998) about the relationship between productivity and health. There is most empirical study that examine government health expenditure have a negative or in other word not significant effect on growth. The method this study used is the meta-analysis of economics research network (MAER-Net), where it reflects transparency and the best practice in meta-analysis. Econometric specification used in primary studies often and it is based on the certain underlying theoretical models. They examine that if its underlying the theoretical models it effects the government expenditure health growth association. Also, controlling this studies base on their specification on the endogenous growth models but excluding studies that adopt the Solow-type growth model. The explanation that suits this study is government health expenditure crowds out the other factors where its contribute to growth or public resources that allocated inefficiently in the health sector. In other words, quality of the government health expenditure overall is low.
Based on Lin Li, Maoguo Wu, Zhenyu Wu (2017), the potential factors that impact the regional economic development is the study of the relationship between public health expenditure and its appear to become more n more important. In this study, its mention about Shandong health expenditure which is higher than in Jiangsu based on statistics. But, it is because of the large population the average of public health expenditure of Shandong a lower than Jiangsu. According to Mayer et al (2008) and Muysken (2008) argue that health has a positive effect on economic growth, where healthy life is a requirement of an effective labour force and by measuring the roles of several aspects in promote this economic growth. According to Lin Li, Maoguo Wu, Zhenyu Wu (2017) study, Mohapatra and Mishra (2011) states the growth of Gross State Domestic Product (GSDP) will cause an increase in health expenditure in both long-run and short-run, but the health expenditure only effect GSDP in long-run. So, the GSDP can affect the health expenditure only in short-run. Theoretical model that been used in this study are based on the Constant Elasticity of Substitution production function (CES) and only considers capital, labour and technology in the production function..
According to Elizabeth N. Appiah (2017), in developing country well-being they does not only apply the poor health, but it is a global matter. In addition, because of the low level of health expenditure as a percent per capita GDP in developing countries, the communicable diseases such as tuberculosis and diarrhoea where it recognizes with no borders, as to remain an ever-emerging threat to those in developed countries, as much they do in developing countries. In this study, Fazaeli et al. (2016), argue that investment on health in GDP in developed countries are larger than in developing countries. This imply on the level of economic growth increases as well as the health expenditure growth. The study uses panel data of 139 developing countries with period 1975-2015 which is 35 years. This is from the World Development Indicator(WDI) data from World Bank (2017). This study also uses Keynesian modelling which hypothesizes the expansion in government spending stimulate the economic growth. Even though this theory did not follow the policy maker, it is still believe that the increase in government spending have a positive effect on GDP growth. Elizabeth N. Appiah (2017) found that the total expenditures as a percent of gross domestic product (GDP) has a positive effect on the total output and also makes the impact increased in aggregate demand and expenditure. Appiah And McMahon (2002) also exposed that the non-monetary benefits of investment in education have an indirect effect on better health.
The health expenditure in developing countries cannot make a positive impact on per capita GDP growth if the investment in health are not stabilized. Therefore, government have set the budget on the health sector to improve the public and private health care in order to produce huge number of healthy human capital that can contribute more production to increase the economic growth. According to Hashmati A. (2001) has stated that the health expenditures in developing and developed countries have great impact on economic growth. From his observation, he used Solow growth model to investigate the effect of the health expenditures on the economics growth based on sample of OECD countries from 1970 to 1992, in the result he concluded that there is a positive relationship between health expenditures and growth. Based on Li Huang (2009) studies between per capital real GDP growth and the physical capital, human capital and health investment in production function.
Muskin (1962) showed that human capital can be accumulated through improvements in health and capacity of work suggesting that improved nutrition and health status affect labour productivity positively. Investment in health care is found to have positive effects on economic growth as a healthy nation have higher productivity. It should be noted that the proxy for investment in health capital is the proportion of income spent on health, while Knowles and Owen used life expectancy to proxy heath capital. Hence, health care expenditure per capita is an appropriate proxy for investment in health. Makiew et al. (1992) found that human capital accumulation can potentially alter the theoretical or empirical analysis of economic growth. Leaving out human capital affects the coefficients on investment and population growth. Analogously a disaggregation of capital into physical, human and health capital investments has both theoretical and empirical implications. The coefficient of initial value of GDP is negative indicating positive relation between growth and the initial distance from the steady state. The coefficient of investment in capital is positive showing that growth is an increasing function of saving. The coefficient of human capital is unexpectedly negative and insignificant.
However, most of the studies still remain question how health is created. Odusola (1998) has investigated the correlation between investment in human capital and growth of economic activities. He used Nigerian data and discovered the health expenditure on economic growth and GDP over the period 1985-2009. He documented that the funds are properly appropriately expended to both the recurrent and capital project in health. He concluded that the existence of a positive relationship between health and GDP growth will be more widened. The regression accounted for 92% of the sample variation on health expenditure and showed that the fraction of expenditure devoted to health care of total GDP increases with GDP. In an Engel curve context, this implies that health care is a ”luxury” good, and Newhouse concluded that at the margin health expenditure buys ”care” rather than ”cure”. Based on Guisan (2009), countries with high levels of health expenditure per capita is linked with the quality of health services and gives a positive impact on health indicator on life style. Generally, health expenditure increases and the outcome will be positive effect on health and life satisfaction.
In further review by Khan H. N., Razali R. B., and Shafie A. B. (2016) have concluded that the population growth and population structure have negative effect on health expenditure, as the hypothesis showed the income per capital have significant impact on health expenditure with income elastic for health expenditure 0.999 ; 1. Thus, when the population become larger, the income per capital that citizen have will be lesser compare with the smaller population income per capital. Lastly, according to Kar and Taban (2005) determined that the relationship between health expenditure and economics growth by using co-integration method is opposite. Therefore, the relationship between health expenditure and economic growth is versa vice and is difficult to confirm. It depends on the different methodology, data, country group, period and result used to investigate.

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Conclusion
Malaysia is one of the Southeast Asian countries which have fast growing and high middle income economy country. According to the World Health Organization (WHO) stated that Malaysia have spent a total of US$ 938 billion in healthcare with a great growth rate of more than 4.49% in health expenditures. In 1997 and 2012, there are out of 4.49% of GDP on its total health expenditure. Based on the Malaysia Ministry of Health report (MOH) (2014), the share of health care financing expenditure was separate as 44% from MOH, 37% from out of pocket, 7% private insurance and 4% from other health federal agencies. The growth of health expenditure is 4.49% when compared to the annual GDP growth rate of 6%. From the data it represents that the constant increase in health expenditure growth rate, however, it might have negative impact on the growth process of economy become slow. In addition, the situation may lead to a burden on country’s GDP in the form of deficit budget in health care sector and citizens may suffer for the out of pocket expenditure on health care.
According to Getzen (2014), money spending and health care expenditure relationship has long been established. Better health has been identified as an important factor to raise economic growth and increased productivity. A healthy population of any country is of important importance and has positive connections to economic growth (Sachs, 2002; Khan et al., 2015). However, rapidly growing of health care expenditure is a matter of serious concern. The fast growth rate of health care spending exerts pressure on various sectors of the economy, which might slow down the economic growth sustainability (Jakovljevic and Milovanovic, 2015; Jakovljevic, 2016) create poverty trap, as more out-of-pocket health expenditure hugely affects household income (Khan et al., 2015).
Furthermore, rapid population growth has raised serious concerns about the improvements in health status of the general public, health care systems’ financial sustainability, both in developed and developing countries as well. The increasing trend of health care expenditure in Malaysia has be a serious concern for policy makers and decision makers. There is a mutual relationship between the population’s level of health and its economic growth and development level. A great health status and circumstance enable a country’s sustainable growth and development. At the same time, the level of growth and development contribute to the new health care technology access to the population and provide better health treatment. Therefore, the share of the population of healthy individual rises, production contribute by the human capital improves, loss of human capital does not exist and thus the number of the labour supply in the market increases. Due to the fact, people who are healthy mentally, physically and spiritually are expected to provide more production than the disabled and sick people, thus more productivity emerge in the market and have a positive effect on the economic growth. In summary, all the review on the correlation between health expenditure and economic growth provided the fact that both variable are positive and significant effect of health expenditure on economic growth. However, it may depend on the magnitude of the government budgetary to health sector
Lastly, the findings of the paper provide an insight to the policy makers that health expenditure play a significant role in the economic development of Malaysia. Therefore, to create healthy, efficient, technologically skilled and productive labor force it is suggested that encouraging HCE policies be adopted in Malaysia. Based on Culyer (1989) and Di Matteo (2003), health expenditure is being a necessity, this stresses the role of government control and intervention in the delivery of health care. Ministry of Health Malaysia (MOH) should provide basis health facilities as well as promote health education to the common people of the country with a special emphasis on rural health.

Schultz T.W. (1961). Investment in Human Capital. The American Economic Review, 51(1), 1-17. Retrieved from https://s3.amazonaws.com/academia.edu.documents/5598085/schultz.pdf?AWSAccessKeyId=AKIAIWOWYYGZ2Y53UL3A;Expires=1523132677;Signature=lhC1qaTAiF8KwGx4GeEK6xnkf4A%3D;response-content-disposition=inline%3B%20filename%3DInvestment_in_human_capital.pdf

CHAPTER 2

LITERATURE REVIEW

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2.1 Introduction

This chapter is discussing on the previous of related studied done by other researcher. In this chapter, an overview of demand of high rise building and wind behavior in Malaysia are discussed. The existing lateral system such as shear wall and proposed new system, space shear wall are also discussed. The lateral performance of high rise building is also presented when exerting lateral loading.

2.2 High Rise Building

A ‘tall building’ is defined as a multi-story structure in which most occupants reach their destinations on higher floor depend on elevators (lifts) (Craighead, 2009). This tall building can be categorized as low, mid, high and super high rise (skyscraper). The low rise building is defined as less than four stories, mid rise is considering from five up to fifteen stories, while high rise is ranging from sixteen to fifty and more than fifty stories is the skyscraper (Fadzil, 2016).

Besides, The National Fire Protection Association (NFPA) defined a high-rise building as a building taller than 75 ft (23 meters) in height measured from the lowest level of fire department vehicle access to the floor of the highest occupiable storey (Mohamad Yatim, 2009). Another opinion says a high-rise structure is one that extends higher than the maximum reach of available fire-fighting equipment and it is between 75 ft and 100 ft (23 meters to 31 meters) (Craighead, 2009).

The overall slenderness of a high rise building is defined by its “height-to-base ratio”, being the height of the building divided by its narrowest plan dimension. Basically, higher height-to-base ratios and lower natural frequencies increase the dynamic component of the response to wind. A building with a height-to-base ratio of more than around 5 is expected to respond to wind loads in a significantly dynamic way (where building inertial effects are significant) (Kayvani, 2014).

In fact, New York’s most advanced towers are defined not by their height but by their width or rather, their slenderness. The slenderness ratio is defined as the ratio between a building’s height and its smallest width. For example, a 1,000ft (310m) height of tower that has 100ft (31m) at its narrowest width would have a slenderness ratio of 10:1. “The slenderness of a building is maybe more important than anything else,” said by Silvian Marcus, director of building structures at WSP USA (Runaghan, 2014). In New York’s building code, designs for buildings over 600ft (183m) and any building with a slenderness ratio above 7:1 must be peer reviewed by another engineering practice (Runaghan, 2014).

Therefore, the issue of slenderness must also be considered. A measure of a building’s slenderness is the aspect ratio. For core wall only lateral systems, ratios typically range from 10:1 to 13:1. For lateral systems that engage exterior elements, an aspect ratio up to 8:1 is feasible. Pushing this ratio up to 10:1 can result in the need for special damping devices to mitigate excessive motion perception (Zils & Viise, 2013). The space shear wall system is considered as exterior lateral element, due to the consideration of authenticity in real construction, the ratio used in this research is 4:1.

2.2.1 Demand of High Rise Building

Nowadays, due to the increasing of population in urban areas in Malaysia such as Penang, Kuala Lumpur, Selangor and Johor Bahru, demand for housing is increasing and development of high-rise residential schemes is accelerated in these high-density areas due to scarcity of land for development of landed residential properties (Tiun, 2009). These high rise properties are being promoted because high rise living became a logical response to soaring of land prices. There are successful example countries that implement high rise such as Singapore and Hong Kong where the traditional lifestyle is high-density, high-rise living (Tiun, 2009).

In Penang, there is a trend of developers preferring to build tall building such as condominiums. In coming years, especially on Penang Island, there is a higher proportion of new high-rise units (Lim, 2015). According to Table 2.1, on the statistics obtained from the National Property Information Centre (NAPIC), it is estimated that there were at least 203,618 units of high rise properties inclusive of flats, condominiums and apartments are under constructing for incoming supply in Malaysia by the end of 2017 and the number is growing yearly. From the data, Penang is the third highest state in constructing more high rise building which is about 35,793 units. This is due to the high demand of housing in this developing area.

Table 2.1: Incoming Supply of High Rise Building in Malaysia as of Q3 2017

State Low Cost Flat Flat Condominium/ Apartment Total
Selangor 2887 6255 43859 53001
W.P. Kuala Lumpur 0 0 40460 40460
Pulau Pinang 7280 8256 20257 35793
Johor 2451 4451 13011 19913
Sabah 3562 418 12426 16406
Sarawak 0 0 8801 8801
Table 2.1 – continued

Perak 0 724 6264 6988
W.P. Putrajaya 0 0 6944 6944
Pahang 0 840 3488 4328
Negeri Sembilan 0 1684 1588 3272
Kelantan 218 1001 1451 2670
Melaka 250 324 1392 1966
Terengganu 640 35 612 1287
W.P. Labuan 0 0 1143 1143
Kedah 416 0 196 612
Perlis 0 0 34 34
Malaysia 17704 23988 161926 203618

Source: Residential Property Stock Table Q3 2017, NAPIC.

2.3 Size of Column and Beam

Based on a study on wind behavior of buildings with and without shear wall (in different location) for structural stability and economy (Gourav P. Bajaj, 2016), the column size is 600 mm x 600 mm and beam size is 500 mm x 300 mm. The building dimension is 20 m in length and 15 m in width with a height of 47.6 m. The research is about determination of shear wall application toward wind load which is similar to this study, the dimension of building is also almost similar in this study. Therefore, the size of column and beam is determined as 600 mm x 600 mm and 500 mm x 300 mm respectively.

2.4 Shear Wall

Shear wall is a structural element installed in a building to resist horizontal forces parallel to the plane of the wall. Due to its highly in plane stiffness and strength, it can resist large both horizontal loads and support gravity loads simultaneously (Sardar & Karadi, 2013). The main horizontal forces that are induces by the shear wall are wind, earthquake and other lateral forces. They are mainly flexural members and mostly provided in high rise buildings to avoid the total collapse of the high rise buildings under seismic forces, wind forces or other lateral forces (Gourav P. Bajaj, 2016). Figure 2.1 and Figure 2.2 show the construction of shear wall in high rise building.

Sources: Kopczynski, 2011

Figure 2.1: Construction of shear wall of 40-storeys residential tower at Eighth and Pine.

Sources: PERI Group, 2017

Figure 2.2: Construction of shear wall of 26-storeys Aspen Residence in George Town, Malaysia
When the buildings are tall, which are more than twelve storeys or so, the sizes of beam and column need to be constructed larger and reinforcement at the beam and column junction works become heavier, therefore, there is a lot of obstruction at to place and vibrate concrete at these joints, which generally will affect the safety of buildings (Gourav P. Bajaj, 2016). So, the present of shear walls in high rise buildings solves these practical difficulties. However, recent RC tall buildings would have more complicated structural behavior than before. Shear wall system with irregular openings are that undergoes both lateral and gravity loads, and may result some especial issues in the behavior of structural elements and stability of structure (Abd-El-Rahim & Farghaly, 2010). Besides, installation of openings in the shear walls can affect on the top displacements of the buildings and it is related with openings arrangement system of openings. The top displacement is agreed quit well with that induced in shear walls without openings but this obstructs the transmission natural lighting into the building (Abd-El-Rahim & Farghaly, 2010). Therefore, new system called space shear wall which is a combination of shear wall and space frame structure is introduced to modified traditional shear wall.

2.5 Space Frame Structure

Space structure is defined as a three-dimensional structural system assemble in single, double or multiple layer with interlocked strut elements & joint-connections (Bayat et al., 2014). Besides, innovation of space structures provided the domineering features emphasizing the giant impact exerted by three-dimensional structures upon modern architecture and structural engineering (Makowski, 2018). Space frame connection is the most determinant component in order to connecting linear members and distributing the imposed loads in three-dimensional manner (Bayat et al., 2014).

The space frame can be formed either in a flat or a curved surface. The earliest form of space frame structures is a single layer grid. By adding intermediate grids and including rigid connecting to the joist and girder framing system, the single layer grid is formed. The major characteristic of grid construction is the omni-directional spreading of the load as opposed to the linear transfer of the load in an ordinary framing system. Since such load transfer is mainly by bending, for larger spans, the bending stiffness is increased most efficiently by going to a double layer system. The load transfer mechanism of curved surface space frames essentially different from the grid system that is primarily membrane-like action (Wai-fah, 1999).

A good example of space structure is Baltimore-Washington International Thurgood Marshall Airport (BWI Airport) shown in Figure 2.1. Baltimore-Washington International Airport is an international airport located in Linthicum, an unincorporated community in northern Anne Arundel County, Maryland, United States. The airport has the signature space frame design while increasing passenger capacity and improving the traveler’s experience. The design is a 90-foot atrium, topped by a large skylight, floods the upper and lower levels, including waiting and shopping areas, with natural light, while supported by the steel space frame elements. This project even won the WBC (Washington Building Congress) Craftsmanship Award for the Metals/Structural Steel Categories (Airport Technology, 2018).

Sources: Airport Technology, 2018

Figure 2.3: Space frame structure of Baltimore-Washington International Thurgood Marshall Airport

The advantage of a space frame structure is lightweight properties. The material is distributed spatially in such away that the loads transfer mechanism are primarily axial loads which are in tension or compression (Makowski, 2018). Furthermore, space frames can be built from simple prefabricated units, which are often of standard size and shape. Such units can be easily transported and rapidly assembled on site by semi-skilled labor. Besides, space structure compatible with architecture aspect. Architects appreciate the visual beauty and the impressive simplicity of lines in space frames. A trend is very noticeable in which the structural members are left exposed as a part of the architectural expression. Desire for openness for both visual impact as well as the ability to accommodate variable space requirements always calls for space frames as the most favorable solution (Wai-fah, 1999).

2.6 Space Shear Wall

Space Shear Wall is space trusses to resist the lateral forces generated by the wind activities. Such lateral forces may be resisted quite effectively by integration of three-dimensional structures with two dimensional lateral systems like cross bracing, where the building frame is designed to carry the vertical loads, and the bracing the lateral force (Bayat et al., 2014). The concept of space shear wall can be simplified as the combination of shear wall and space structure. Figure 2.2 shows the initial concept of space shear wall.

Sources: Bayat et al., 2014

Figure 2.4: Initial Concept of Space Shear wall

The idea of Space shear wall is based on the capability of space trusses to resist the lateral forces generated by the seismic activities or wind activities. These lateral forces may be resisted by integration of three-dimensional structures with two dimensional lateral systems quite effectively where the building frame is designed to carry the vertical loads, and the space truss resists the lateral force (Sutjiadi ; Charleson, 2014).

The expected advantages of space shear wall are high stiffness, ductility and energy dissipation, lightness, industrialization, maintainability and reparability, compatibility with architectural considerations, low cost, simple and fast fabrication. These advantages are expected based on the structural performance of space truss under past earthquakes and its unique characteristics (Bayat et al., 2014).

Space structure is high stiffness due to its three-dimensional geometric and proper contribution of loading by its interconnected elements (G.S. Ramaswamy, M. Eekhout, G.R. Suresh, 2002). Table 2.2 shows a list of famous space structures with their free span length and carried dead load. The large free span and imposed heavy load in existing space structures demonstrate the high stiffness of space structures.

Table 2.2: Examples of Famous Buildings Using Space Frame Structures

Project Free Span (m) Dead Load (kPa)
Currigan Hall 55 –
Sao Paulo Exhibition Center 60 –
Boeing 747 Hanger, London Airport, 1970 84 11.1
Omni Coliseum 107 7.3
Expo 68, Osaka 108 15.2
Pauly Pavilion 122 7.8
Kloten Airport, Zurich, 1975 128 18.8
Nartia Airport, Tokyo, 1972 190 25.6

Source: Bayat et al., 2014
Besides that, space shear wall is compatible with architectural consideration. Architects always wish to design long vertical structure with fewer structural components (Sutjiadi ; Charleson, 2014). Therefore, there is development of space structures in previous years. Space frame structure is a precious system that can optimise between engineer and architect to create a new forms, that provide wider application, flexibility and diversity. High intention by one of the most famous architects, Lord Norman Foster, is frequently applying the exposed spatial structural elements in his architectural design, as shown in Figure 2.6 (Bayat et al., 2014). By using space shear wall, the integration between structural and architectural elements can be improved and investigated on its challenges in high-rise buildings as demonstrated in Figure 2.5 (Sutjiadi ; Charleson, 2014). Therefore, space shear wall would be introduced as a compatible lateral resisting system for architectural considerations.

Sources: Sutjiadi ; Charleson, 2014

Figure 2.5: A Section of Three-Storeys Building Using Boundary Double-layer Space Structure

Source: Bayat et al., 2014

Figure 2.6: Architectural-Structural Integration of Space Grid Structures a) 30 St Mary Axe, London b) Hearst Tower, New York c) Almaty Twin Tower, Almaty d) Double-Layer Space Structure of an un-built 150 storeys Project, Chicago e) Gakuen Spiral Tower, Nogoya f) Skytree Tower, Tokyo International

2.7 Lateral Load

Lateral loads are defined as the live loads in the form of horizontal force acting on the structure. Typical lateral loads would be a wind load against a facade, an earthquake, the earth pressure against a beach front, retaining wall or the earth pressure against the basement wall (Hoogendoorn, 2009). Most lateral loads vary in intensity depending on the buildings geographic location, structural materials, height and shape. The dynamic effects of wind and earthquake loads are usually analyzed as an equivalent static load in most small and moderate sized buildings (Brownjohn, 2015).

2.7.1 Wind Behaviour

Wind is a phenomenon of great complexity because of the many flow situations arising from the interaction of wind with structures. Wind has some negative and positive effects. For structural engineers, it always causes trouble with height (Lotfabadi, 2014). The average wind speed over a time period of the order of ten minutes or more, tends to increase with height (Mendis et al., 2007). Therefore, high rise building which is tall or slender, respond dynamically to the effects of wind. In Penang, an estimation of maximum wind speed at a building with height of 145.6m was conducted and indicated the value of 29.85 m/s (Deraman ; Chik, 2014). According to Malaysia Standard (MS1553:2002), the basic wind speed of Penang which categorised as Zone II is about 32.5m/s.

2.7.2 Wind Load

The principal lateral load this thesis is focused on the wind action. An introduction is presented to wind loading and wind-induced building response. It is tried to combine both wind engineering and the building code prescriptions (Hoogendoorn, 2009). The recommendations of Eurocode 1 are discussed and on occasion compared with the consulted literature on wind engineering (Hoogendoorn, 2009). Practically all building codes consider the wind action as a quasi-static load. To allow a static structural calculation, factors are introduced accounting for the spatial and temporal averaging of wind gustiness and the dynamic amplification of the building response (Patruno, Ricci, de Miranda, ; Ubertini, 2017). Eurocode 1 defines the wind load acting on any structure or element by:

x

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