Transcript of "Primary health care reform in 1 care for 1 malaysia"
International Journal of Public Health Research Special Issue 2011, pp (50-56)Primary Health Care Reform in 1CARE for 1 MalaysiaDr. Kamaliah Mohamad NohFamily Health Development Division, Ministry of Health MalaysiaABSTRACT element within primary health care that focuses onPrimary health care is an approach to health and a health care services including health promotion,spectrum of services beyond the traditional health management of illness, injury prevention andcare system while primary care is just one element personal care.within PHC that focuses on health care services. Healthcare services in PHC has a dualThe present status of PHC in Malaysia and the function of directly providing services at point ofstrides it has made in uplifting the health status of first contact and a coordinating function to ensurethe nation is described. The challenges that the continuity of care and ease of movement across theMalaysia health system are facing have necessitated system for individuals in developing their health.a review of the structure of the whole health system Primary health care providers consist of aand reforms in PHC will ensue in due course. The team of physicians, assistant medical officersconcept of 1Care, the proposed re-structuring of the (AMOs), nurses and community nurses,health system, is discussed with emphasis on the pharmacists, medical laboratory technologists,reform in the PHC delivery system. The reforms are pharmacist assistants, physiotherapist and theaimed at addressing three main concerns on listing grows longer as the scope of services at PHCseamless integration of care especially for the becomes more comprehensive.management of chronic diseases, ensuring universalcoverage and responsiveness of the health system in PRESENT HEALTH STATUSthe face of increasing client expectations and The Malaysian PHC delivery system providespatient safety. The opportunity for macro reform to population-based services using a life-courseimprove the health of Malaysians by developing a approach in delivering services from womb tosustainable and high performing health care system tomb. The health of Malaysia’s population hasis being seized by the Ministry of Health in 1Care. benefited from a well-developed primary healthThe micro reforms are discussed as regards to care system, together with improved access to cleanincreasing access to services, development of water and sanitation, and reinforced by programs toprimary health care teams to deliver comprehensive reduce poverty, increase literacy, and build aPHC, the application of ICT, the renewed emphasis modern infrastructure.on health promotion & prevention activities and a Malaysia has made great gains in liferenewed focus on community empowerment and expectancy for its people. Life expectancy at birthparticipation. Support in terms of human resource, rose between 1970 and 2008 for men from 61.6 togovernance & funding models, capacity building in 71.6 years, and for women from 65.6 to 76.4 yearsmonitoring & evaluation as well as change (Table 1): similar to the average life expectancy ofmanagement to affect the reforms are identified. 72 and 76 years for men and women respectively inThe paper concludes with lessons learnt from other 2006 in the Western Pacific Region of the Worldcountries and the importance of systemic reform for Health Organization. Infant mortality droppeda well functioning health delivery system. substantially between 1970 and 2008 from 39.4 to 6.4 deaths per 1000 live births: just above AustraliaINTRODUCTION with 5 per 1000 and Singapore with 3.2 per 1000.Primary Health Care refers to an approach to health Maternal mortality in that period dropped from 1.4and a spectrum of services beyond the traditional to 0.3 deaths per 1000 live births.health care system while primary care is theTable 1 Mortality and health indicators 1970 1980 1990 2000 2008 Life expectancy at birth, female (years) 65.6 70.5 73.5 74.7 76.4 Life expectancy at birth, male (years) 61.6 66.4 68.9 70.0 71.6 50
International Journal of Public Health Research Special Issue 2011, pp (50-56) Mortality rate, infant under one year (per 39.4 23.8 13.1 6.5 6.4 1000 live births) Mortality rate, toddler (per 1000 children 1-4 4.2 2.1 0.9 0.6 0.4 years old) Maternal mortality (per 1000 live births) 1.4 0.6 0.2 0.3 0.3Source: Department of Statistics Malaysia, Time Series Data, Population Statistics, accessed athttp://www.statistics.gov.myWHO World Health Statistics 2010 Although non-communicable diseases now reported in 2000 and 2004 but the rate declinedaccount for most mortality and morbidity, thereafter to 1.2 per 100,000 (334 measles cases) incommunicable disease continues to be a threat but 2008. Incidences of polio, diptheria, and whoopinggreat progress has been made in the past decade in cough (pertussis) have been low for the past 20prevention and control as shown in the downward years, and neonatal tetanus has been less than 1 pertrends in Hepatitis B, measles, diptheria, neonatal 100,000 live births (Figure 1). Malaysia began itstentanus, pertussis and HIV, although dengue, national polio vaccination program in 1972, the lasttuberculosis, and malaria remain concerns. Rates of polio outbreak occured in 1977, the last indigenousvaccine preventable diseases have dropped in wild poliovirus was reported in 1984, and no poliorecent years in response to active vaccination cases were detected until 1992 when three importedprograms with high rates of immunization cases were reported. Malaysia was certified ascoverage. polio-free country by the World Health The incidence of Hepatitis B has dropped Organization on 29 October 2000.steadily since 1999 to 3.2 per 100,000 (886reported cases) in 2008. Peaks of measles were 0.3 0.2 For 100,000 population 0.25 For 1,000 live births 0.15 0.2 0.15 0.1 0.1 0.05 0.05 0 -4.44E-1 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Year Diphtheria Polio Whooping cough Neonatal tetanus (1,000 LB)Figure 1 Diptheria, pertussis, neonatal tetanus and poliomyelitis, 1988-2008 From the Rural Health Service Scheme clinics in 1957 to 897 health clinics (primary care(1953-1956) and the three-tier model in the late and maternal and child health) in 1970, and to1950s, the PHC system in Malaysia has developed midwife and community clinics by 2010 (Table 2).in the 1970s into the two-tier system with a health Between 2000 and 2008, approximately 50 healthclinic serving a population of 15,000 to 20,000 centres were amalgamated with hospitals.people and a rural clinic covering 2000 to 4000population. The number of health facilitiesincreased rapidly especially from seven health 51
International Journal of Public Health Research Special Issue 2011, pp (50-56)Table 2 Primary health care facilities, 1957 – 2010 Facility 1957 1970 1980 1990 2000 2010 Community clinic 0 943 1509 1880 1924 1919 Health clinic 7 224 725 708 947 812 Total 7 1167 2234 2588 2871 2731 Private sector doctors also offer a seventh that of the richest 20%. This inequityconsiderable amount of primary health care. A involved disadvantaged groups (indigenous groups,register of medical practitioners in 1967 listed 1759 legal and illegal immigrants), age groups (thedoctors of whom 713 were in government service young and elderly), geographic location (rural(41%) while the other 1046 (59%) were believed to areas), and states (East Malaysia).be in private practice. Lack of Integration of Dichotomous HealthcareTHE NEED FOR REFORM SystemThe challenges to health systems around the world The currently dichotomous healthcare system hasare just as applicable here in Malaysia, namely to our healthcare resources spread between the privatefocus on interventions that will have the greatest and public sectors working in parallel to each other.impact on the poor; countering major threats to The public sector is government funded with thehealth (such as tobacco); universal access to patient receiving almost free primary healthcarehealthcare services and investing in research & services and a largely subsidised secondary caredevelopment. services, while the private sector is fee for service with out of pocket payment or through privateHealth Challenges health insurance and employer payment. With theThe challenges facing the Malaysian health system mismatch between the distribution of healthcareinclude the lack of integration; the changing trends resources and burden of work in the two sectors,in disease pattern & socio – demography; rising the healthcare resources within the country are notpublic expectations; issues of economic optimally utilised. This is especially so in primaryinefficiency in the targeting of limited health fund health care where the public sector has only aboutwith dependency on government subsidized 10% of primary care clinics but handle almost 40%services; retaining highly skilled healthcare of outpatient visits.personnel in the public sector with the limitedappraisal & reward systems for performance; Epidemiological Transition - Chronic Diseasesconflicts of interest as the MOH is the funder, Chronic diseases are the major cause of death andprovider and regulator of health services; disability in Malaysia, accounting for 71% of theaccessibility & affordability with discrepancy of mortality and 69% of the total burden of disease.health outcomes; limited coverage of catastrophic The prevalence is increasing and the relative lack ofillness (haemodialysis, cancer therapy, transplants emphasis on health promotion and diseaseetc.) and the pattern of private spending for health prevention in the outpatient setting calls intoovertaking public spending. It has been shown that question the adequacy of the acute care paradigm.when a majority of health care is privately funded, The concept of caring for long term healththere is less control on health care inflation. problems needs to replace it. Innovative and cost-Consequently, cost of health care in such situations effective community-based interventions need to bewill rise even faster. Medical inflation is usually translated into high quality population-wide chronichigher than overall inflation. disease care to counter the challenge posed by the epidemic of chronic diseases. With these challengesEnsuring Equity in Health confronting the health system, there is a concern onStrong economic growth has allowed Malaysia to access to continuity of care with the varioussignificantly reduce overall poverty levels but providers apparently working in silos, not onlyinequality, however, remains a challenge. The gap between the public and private sectors of ourbetween rich and poor has widened and income dichotomous health system but also within thegrowth has been strong only for the top 20% of public sector, between facilities and across theMalaysian income earners. The bottom 40% of various disciplines. This is exemplified in the casehouseholds have experienced the slowest growth, mix in the public and private primary care clinics.earning less than RM1500 monthly, barely one- The public clinics manage larger proportions of chronic diseases as compared to the private sector. 52
International Journal of Public Health Research Special Issue 2011, pp (50-56)Ensuring Universal Access basic training. Universities and training collegesWhilst we are grappling with the challenges offering training in medicine and health sciencesbrought about by epidemiologic and demographic have to achieve standards set by the Ministry oftransition, there are still areas in the country with Higher Learning. The Malaysian Medical Councilproblems in accessing primary care services, (MMC) maintains standards of medical educationparticularly in rural and remote areas, but also in in the country as for their medical degrees to beurban centres where the lack of after-hours services recognized, the training institutions have to beoften results in the use of emergency rooms for inspected by the MMC. All those who delivernon-urgent care. To meet the increasing demands of clinical services are mandated by Law to bethe public, efforts have been made to extend the registered with their professional bodies, doctorsoperational hours of the public clinics, but with no with the Malaysian Medical Council (MMC), andsupporting increase in human resource, this has physician assistants and nurses with their respectiveraised the providers’ concerns regarding their work professional Boards. The professional bodies selflife balance. regulate the proficiency of their members through the setting of standards and enforcement of ethicsPolicies and implementation strategies have and codes of conduct. Legislation, both the Medicalevolved with the changing needs of the population and Nursing Acts, amongst others are also in placeand the growing capacity of the health system. In to prevent unqualified personnel from practising as2010, health clinics delivering only curative care health care workers in substandard facilities.for minor ailments and minor procedures were setup in urban areas, strategically located in residential Quality Servicesareas for the urban middle class and poorer groups. The Ministry of Health has developed a culture ofThese Klinik 1Malaysia (K1M) are manned by quality care with recognition of initiatives at theassistant medical officers and nurses and offer ground level, through competitions for models ofservices from 10 am to 10 pm daily. The response good practice, quality control circles, innovation forhas been so good that from that initial 50 that were solving local problems, as well as setting qualityoperationalised in 2010, another 28 have been standards nationwide, supported by theoperationalised till January 2011. In an effort to development of practice guidelines. In the mid-expand the present mobile clinic services for the 1980s, the Ministry of Health began to work on therural areas, buses and boats equipped as mobile quality of care, as part of the Quality Assuranceclinics have been introduced at the end of 2010. Programme and Quality Management System byThese differ from the traditional mobile clinics in tracking indicators of quality of care at the nationalthat there are now doctors manning theses services level. The implementation of the nationwide qualityand the clinics can be run in the vehicle itself. assurance programme of the Ministry of Health since 1994 has set quality standards to ensureRising Expectations attainment of service goals. More recently (2000), clinic–specific quality standards have been set forPerson-Centred Services PHC services in Malaysia, including for diabetesThe findings of the World Health Survey 2000 management, asthma management, appropriateinstigated improvements in selected facets of the hospitalisation, client-friendly clinic, pathologyMalaysian health care system to upgrade the services, radiology services, and pharmacydelivery of services so as to be more responsive to services.patients’ expectations. However, increasing client An initiative to ensure the provision ofexpectations has posed concerns on the health quality healthcare in health clinics is thesystem’s responsiveness. The monitoring of improvement of the work process by developingcomplaints through well-established channels practice standards and guides for credentialing and(complaints boxes, media (email, telephone, verbal) privileging of clinical staff, standard operatingto the Minister of Health and Director General procedures, and comprehensive guidebooks toHealth, the Chief Secretary of the Government and guide the clinic staff on managing and coordinatingto the Bureau of Public Complaints in the Prime the activities of the clinic, ranging from clinicMinister’s Department) has shown that the administration, environmental sanitation to patientcommunity’s concerns with the responsiveness of care.the healthcare system remain. The majority are dueto lack of communication skills of the providers. WAY FORWARD - 1CARE FOR 1MALAYSIAPatient Safety As the country approaches developed status, asPatient safety is addressed by ensuring competency demographic and epidemiological transitionsof healthcare workers through practice standards, continue, and as new technology expands thelegislation, credentialing and privileging. possibilities for intervention, the demand for healthCompetency of health care workers starts with care by the population will continue to rise, putting 53
International Journal of Public Health Research Special Issue 2011, pp (50-56)pressure for health reform. In strengthening the early to maintain wellness and to delay onset ofhealth care system to meet the challenges posed by sickness, not merely providing curative care to thedemographic & epidemiologic transition, higher sick. Leading the primary health care teamexpectations of the population and escalating health including allied health professionals andcare cost, the Ministry of Health has proposed paramedics as well as with NGOs and civil1Care for 1Malaysia in 2009 - a restructuring of societies in the communities, the PHCP providesthe country’s health care system to align it with team-based care, especially for people with chronicMalaysia’s aspiration to become a high income health conditions, leading to improvements in thenation. management of chronic diseases, which accounts for 40 to 70% of health care system costs. AsTarget of Reform experience in other countries has shown, theThe aim of health reform is to have one integrated coordinator-of-care and gate-keeping role of thenational system where both the public and private PHCP is facilitated by the financing mechanismsectors have managed growth and the resources are with payment by capitation with case-mixoptimally utilised. Presently, the only means to adjustments and incentives for promotive,manage the private sector is through the Private preventive and team-based care; and additionalHealthcare Services & Facilities Act whose incentives for achieving performance targets and asenforcement leaves much to be desired. With inducement for working in less desirable areas.reform we want healthcare of better quality to beprovided by both sectors with common standards The PHC Health Delivery Systemand equal monitoring. Universal access can be The patient will find it more convenient in theimproved with anybody who needs care being able reformed system as he can choose the PHCP heto receive it at their convenience. This is facilitated wants to register with within the community eitherby reform in healthcare financing and the attributes in public or private sector. The first point of contactof social health insurance in promoting social for the patient is the PHCP where they receivejustice and solidarity as well as financial treatment and then return home. If the patients needsustainability, makes it the logical choice in referral for specialist care or hospitalisation,alignment with Malaysia’s social policies. arrangement will be made by the PHCP to seekEverybody will contribute (mandatory inclusion) treatment either in public or private hospitals. Uponwith a community-rated premium; the rich, young completion of treatment, the patient will beand healthy subsidising the poor, elderly and returned to the PHCP. Even though patients aredisabled, respectively. The government will registered with their PHCP, they still have a choicecontinue its function of providing a social safety net to seek treatment from other providers by payingfor the vulnerable groups by subsiding for their OOP or through PHI. Primary health care reformpremium but the subsidy will be more targeted to will increase opportunities to improve access tothose in need, unlike the present system where all, primary health care physicians with innovativerich and poor alike, benefit from universal appointment scheduling, shifts in physician workgovernment subsidy. Individuals still have a choice hours, after-hours clinics and widespreadof accessing services not in the benefit package and availability of primary care physicians with public-hotel services by paying out of pocket or taking private integration.private insurance for top up. Healthcare providershave a choice to enter the system or not as they can The Reformed MOHstill cater to this group of patients who pay out of The MOH will be a leaner organization with verypocket or who have private health insurance. highly specialized functions. It becomes more technocratic and less bureaucratic. The primaryPHC – Thrust of 1Care focus is governance and stewardship whichThe thrust of this reformed health system is primary includes policy and strategy formulation, evaluationhealthcare, where the primary health care physician and planning for implementation; standards setting(PHCP) acts as the hub of person-centred care, and regulation, monitoring and evaluation,coordinating the care needed to deliver legislation and enforcement activities. Policies andcomprehensive and continuous care, no matter what development will encompass aspects as standardthe setting, whether in the primary health care setting, quality and clinical guidelines, cost-clinic, in the hospitals for secondary care for acute effectiveness, HTA, training, ICT and physicalconditions or in the community for self care, home infrastructure. For the regulation functions,nursing etc. The PHCP manages the patient in the legislations will be streamlined for all disciplines.context of his family and the community he comes Enforcement can be located either within the MOHfrom with the support available for his well being, or an independent body depending on the authorityin short being cognisant of the broader determinants and responsibility. A very important function nowof health, with links to public health. The PHCP in MOH will be the monitoring and evaluationlooks at the full spectrum of disease, intervening (M&E) to ensure that the autonomous arms of 54
International Journal of Public Health Research Special Issue 2011, pp (50-56)MOH function according to their specified tasks dichotomous healthcare delivery system with aand objectives, and that standards, guidelines and single purchaser who is separate from the provider.regulations are adhered too. The MOH retains some public health THE JOURNEY TOWARDS PHCservices mainly through the centre for disease REFORMcontrol, research and other services. These services Strengthening of the primary health care system iswill be delivered through the existing state & needed for primary care to play its care-district set-up and through partnership with local coordination and gate-keeping role effectively withauthorities and MHDS. There will still be some obstacles to continuity and coordination of care aredelivery of community health services, namely clearly identified and removed. A culture ofcommunicable disease control. accountability, performance measurement, and Various functions of MOH will now be quality improvement will support targeted fundingunder several autonomous bodies such as Drug tied to expected outcome with governance andRegulatory Agency, Health Technology funding models which support team-based careAssessment and professional bodies such as MMC needs to be strengthened. The important role playedand MDC. by the broader determinants of health is given due recognition with links to public health services atThe Autonomous Healthcare Delivery System the district level.The delivery of health care will be devolved to theautonomous Malaysian Health Care Delivery Infrastructure support for PHC systemSystem (MHDS) comprising public and private The support needed include an adequate healthhealth care providers and this increased autonomy infrastructure and an adequate supply of healthallows it to be more responsive to the population human resource with the right skill mix to support ahealth needs and expectations. The scope of team approach focused on patient needs. Theautonomy of the independent MOH-owned bodies existing primary health care team consists of theis as not-for-profit organisations, accountable to the physician, dentist, pharmacist, assistant medicalMOH and with independent management boards. officer, nurse, community nurse, medical laboratoryThey manage their own budgets i.e. self technologist, assistant pharmacist, assistantaccounting, with the ability to hire and fire and with environmental health officer, public healththe flexibility to engage and remunerate staff based overseer, health attendant and clerical staff. Humanon capability and performance. resource development in 1Care encompasses all Health services will be purchased from categories of healthcare personnel whether inregistered providers including independent Primary primary or secondary/tertiary care. AppropriateHealth Care Providers (PHCP) which include training for health care personnel such as training inprimary care clinics, dentists and pharmacies. management of public providers and managers inPublic hospitals will be coordinated on regional preparation for greater autonomy has to benetworks and funded through a global budget based conducted. The current general practitioners inon case adjustments using DRG. Private hospitals private practice will undergo a conversion to familyservices will be paid through case-based payments. medicine specialists and in the future, only familyOther payment mechanisms apply for dental and medicine specialists will be allowed to open apharmaceutical prescriptions where patients will primary health care practice. The facilities will bemake some co-payments when receiving service. accredited and credentialing & privileging ofBut identified population groups will be exempted primary health care physicians will befrom these co-payments. Payment for services in implemented.the autonomous arms will be based on theirperformance and fulfilment of the MOH ICTspecifications. Information & communication technology is a pre- requisite of the re-structured health system and theHealthcare Financing use of electronic medical records will increaseFunds will be managed by the new National Health opportunities to improve continuity of care as wellFinancing Authority that is publicly owned and as develop the capacity for performanceoperates as a not-for-profit institution. The National management based on targets, coverage and keyHealth Financing Authority (NHFA) will be performance indicators.established to undertake the task of collection of Tele-primary care is one such systemSHI contributions, pooling of funds and which has been developed for primary care indisbursement to healthcare providers. NHFA will Malaysia and its implementation will need to bealso work out the formularies for premiums, pay for hastened to facilitate health reform efforts. Toperformance, unit costs/fees and benefits packages support continuous access to health information andin collaboration with MOH and MHDS. This advice, tele-health and myportal initiatives will bereform allows for integration of the presently used, especially during travel. There are areas in the 55
International Journal of Public Health Research Special Issue 2011, pp (50-56)country lacking IT infrastructure and in these areas The values espoused by the landmarkspecial projects like the universal service provider Alma Ata Declaration, namely equity, universality(USP) have been developed to reach the last mile in and solidarity, are just as relevant today as it wasinformation technology. Telephone advice/health more than 30 years ago. This systemic reform,lines need to be created or enhanced in providing 1Care, subscribes to the PHC approach and the24-hours first-contact services to ensure continuity primary health care model as the foundation ofof care information to be communicated to the health services, with its strong focus on preventingpatient’s regular care provider in addition to after- illness or injury and promoting health. It recogniseshours visits. that various components of health care system are interdependent and that the health care systemsChange management quality and access problems cannot be dealt withGiven the scale of the restructuring, it is imperative effectively unless we pay more attention to primarythat change is managed effectively at all levels of health care. Lessons from other parts of the globestakeholders and explicit change management has argued that the primary health care approachactivities are needed to support all activities. While best "facilitate the integrated management ofdeveloping the blueprint, many more deliberations multiple conditions, a continuum of care, thewith interested parties and stakeholders including engagement of communities, the provision of carethe community will be undertaken. This is to ensure close to home and prevention and health promotionthe development of a solid and widely accepted in addition to treatment and cure."proposal, taking into consideration their concerns.Effective change management will entail initial 1Care is an opportunity with a high potential toinjection of investments particularly for the contribute to a sustainable and high performingrestructured public system in order to compete with healthcare system which subsequently will have thethe private sector on similar footing. potential to impact on the health of Malaysians. A realistic time frame for phasedimplementation is required to ensure that therequisite manpower, infrastructure and ICT needsand challenges are addressed. At the same time,there will be better rationalisation of services as thesystem improves equity and efficiency of servicedelivery according to population needs. Somefacilities may relocate to capitalise on theincentives provided in the restructured system andresponding to the bigger market of health carebuyers throughout Malaysia.CONCLUSIONThe Malaysian health system has performed wellover the years, compared to countries of similareconomic status, in building a system that produceswell-being at a low cost to society (Merican & binYon 2002). The public system has not kept pacewith population growth, however, and the growthof the private health sector means that people inhigher income groups enjoy quicker access toprivate health care, while poorer people have nochoice but to rely on government services 7.Disparities in health outcomes between populationgroups and geographic areas have been reducedalthough 3% of the population reported difficulty in1996 in accessing health care mostly due todistance and transport costs (NHMS II1996).Additional expenditure thus is required to coverneedy population groups, especially in remote areaswhere services are the hardest logistically and mostexpensive per capita to provide. This is especiallypertinent for Sarawak where it has been a greatchallenge to provide universal health care to the“unreachable”, those staying in the remotest areasof the state. 56