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International Journal of Public Health Research Special Issue 2011, pp (50-56)



Primary Health Care Reform in 1CARE for 1 Malaysia
Dr. Kamaliah Mohamad Noh

Family Health Development Division, Ministry of Health Malaysia



ABSTRACT                                                       element within primary health care that focuses on
Primary 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 and
care system while primary care is just one element             personal care.
within PHC that focuses on health care services.                         Healthcare services in PHC has a dual
The present status of PHC in Malaysia and the                  function of directly providing services at point of
strides it has made in uplifting the health status of          first contact and a coordinating function to ensure
the nation is described. The challenges that the               continuity of care and ease of movement across the
Malaysia 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 a
and reforms in PHC will ensue in due course. The               team of physicians, assistant medical officers
concept 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 the
aimed at addressing three main concerns on                     listing grows longer as the scope of services at PHC
seamless integration of care especially for the                becomes more comprehensive.
management of chronic diseases, ensuring universal
coverage and responsiveness of the health system in            PRESENT HEALTH STATUS
the face of increasing client expectations and                 The Malaysian PHC delivery system provides
patient safety. The opportunity for macro reform to            population-based services using a life-course
improve the health of Malaysians by developing a               approach in delivering services from womb to
sustainable and high performing health care system             tomb. The health of Malaysia’s population has
is being seized by the Ministry of Health in 1Care.            benefited from a well-developed primary health
The micro reforms are discussed as regards to                  care system, together with improved access to clean
increasing access to services, development of                  water and sanitation, and reinforced by programs to
primary health care teams to deliver comprehensive             reduce poverty, increase literacy, and build a
PHC, the application of ICT, the renewed emphasis              modern infrastructure.
on health promotion & prevention activities and a                       Malaysia has made great gains in life
renewed focus on community empowerment and                     expectancy for its people. Life expectancy at birth
participation. Support in terms of human resource,             rose between 1970 and 2008 for men from 61.6 to
governance & funding models, capacity building in              71.6 years, and for women from 65.6 to 76.4 years
monitoring & evaluation as well as change                      (Table 1): similar to the average life expectancy of
management to affect the reforms are identified.               72 and 76 years for men and women respectively in
The paper concludes with lessons learnt from other             2006 in the Western Pacific Region of the World
countries and the importance of systemic reform for            Health Organization. Infant mortality dropped
a well functioning health delivery system.                     substantially between 1970 and 2008 from 39.4 to
                                                               6.4 deaths per 1000 live births: just above Australia
INTRODUCTION                                                   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 1.4
and a spectrum of services beyond the traditional              to 0.3 deaths per 1000 live births.
health care system while primary care is the

Table 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                 0.3

Source: Department of Statistics Malaysia, Time Series Data, Population Statistics, accessed at
http://www.statistics.gov.my
WHO World Health Statistics 2010

         Although non-communicable diseases now                                                                reported in 2000 and 2004 but the rate declined
account for most mortality and morbidity,                                                                      thereafter to 1.2 per 100,000 (334 measles cases) in
communicable disease continues to be a threat but                                                              2008. Incidences of polio, diptheria, and whooping
great progress has been made in the past decade in                                                             cough (pertussis) have been low for the past 20
prevention and control as shown in the downward                                                                years, and neonatal tetanus has been less than 1 per
trends in Hepatitis B, measles, diptheria, neonatal                                                            100,000 live births (Figure 1). Malaysia began its
tentanus, pertussis and HIV, although dengue,                                                                  national polio vaccination program in 1972, the last
tuberculosis, and malaria remain concerns. Rates of                                                            polio outbreak occured in 1977, the last indigenous
vaccine preventable diseases have dropped in                                                                   wild poliovirus was reported in 1984, and no polio
recent years in response to active vaccination                                                                 cases were detected until 1992 when three imported
programs with high rates of immunization                                                                       cases were reported. Malaysia was certified as
coverage.                                                                                                      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 (886
reported 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 to
1950s, 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 health
clinic serving a population of 15,000 to 20,000                                                                centres were amalgamated with hospitals.
people and a rural clinic covering 2000 to 4000
population. The number of health facilities
increased 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 inequity
considerable 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 (the
doctors 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 Healthcare
THE NEED FOR REFORM                                           System
The challenges to health systems around the world             The currently dichotomous healthcare system has
are just as applicable here in Malaysia, namely to            our healthcare resources spread between the private
focus 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 the
health (such as tobacco); universal access to                 patient receiving almost free primary healthcare
healthcare services and investing in research &               services and a largely subsidised secondary care
development.                                                  services, while the private sector is fee for service
                                                              with out of pocket payment or through private
Health Challenges                                             health insurance and employer payment. With the
The challenges facing the Malaysian health system             mismatch between the distribution of healthcare
include 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 not
public    expectations;     issues   of    economic           optimally utilised. This is especially so in primary
inefficiency in the targeting of limited health fund          health care where the public sector has only about
with 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 limited
appraisal & reward systems for performance;                   Epidemiological Transition - Chronic Diseases
conflicts of interest as the MOH is the funder,               Chronic diseases are the major cause of death and
provider and regulator of health services;                    disability in Malaysia, accounting for 71% of the
accessibility & 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 of
illness (haemodialysis, cancer therapy, transplants           emphasis on health promotion and disease
etc.) and the pattern of private spending for health          prevention in the outpatient setting calls into
overtaking 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 health
there 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 be
will rise even faster. Medical inflation is usually           translated into high quality population-wide chronic
higher than overall inflation.                                disease care to counter the challenge posed by the
                                                              epidemic of chronic diseases. With these challenges
Ensuring Equity in Health                                     confronting the health system, there is a concern on
Strong economic growth has allowed Malaysia to                access to continuity of care with the various
significantly reduce overall poverty levels but               providers apparently working in silos, not only
inequality, however, remains a challenge. The gap             between the public and private sectors of our
between rich and poor has widened and income                  dichotomous health system but also within the
growth has been strong only for the top 20% of                public sector, between facilities and across the
Malaysian income earners. The bottom 40% of                   various disciplines. This is exemplified in the case
households 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.


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International Journal of Public Health Research Special Issue 2011, pp (50-56)



Ensuring Universal Access                                      basic training. Universities and training colleges
Whilst we are grappling with the challenges                    offering training in medicine and health sciences
brought about by epidemiologic and demographic                 have to achieve standards set by the Ministry of
transition, there are still areas in the country with          Higher Learning. The Malaysian Medical Council
problems in accessing primary care services,                   (MMC) maintains standards of medical education
particularly in rural and remote areas, but also in            in the country as for their medical degrees to be
urban centres where the lack of after-hours services           recognized, the training institutions have to be
often results in the use of emergency rooms for                inspected by the MMC. All those who deliver
non-urgent care. To meet the increasing demands of             clinical services are mandated by Law to be
the public, efforts have been made to extend the               registered with their professional bodies, doctors
operational hours of the public clinics, but with no           with the Malaysian Medical Council (MMC), and
supporting increase in human resource, this has                physician assistants and nurses with their respective
raised the providers’ concerns regarding their work            professional Boards. The professional bodies self
life balance.                                                  regulate the proficiency of their members through
                                                               the setting of standards and enforcement of ethics
Policies and implementation strategies have                    and codes of conduct. Legislation, both the Medical
evolved with the changing needs of the population              and Nursing Acts, amongst others are also in place
and the growing capacity of the health system. In              to prevent unqualified personnel from practising as
2010, health clinics delivering only curative care             health care workers in substandard facilities.
for minor ailments and minor procedures were set
up in urban areas, strategically located in residential        Quality Services
areas for the urban middle class and poorer groups.            The Ministry of Health has developed a culture of
These Klinik 1Malaysia (K1M) are manned by                     quality care with recognition of initiatives at the
assistant medical officers and nurses and offer                ground level, through competitions for models of
services from 10 am to 10 pm daily. The response               good practice, quality control circles, innovation for
has been so good that from that initial 50 that were           solving local problems, as well as setting quality
operationalised in 2010, another 28 have been                  standards     nationwide,     supported     by     the
operationalised 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 the
rural areas, buses and boats equipped as mobile                quality of care, as part of the Quality Assurance
clinics have been introduced at the end of 2010.               Programme and Quality Management System by
These differ from the traditional mobile clinics in            tracking indicators of quality of care at the national
that there are now doctors manning theses services             level. The implementation of the nationwide quality
and the clinics can be run in the vehicle itself.              assurance programme of the Ministry of Health
                                                               since 1994 has set quality standards to ensure
Rising Expectations                                            attainment of service goals. More recently (2000),
                                                               clinic–specific quality standards have been set for
Person-Centred Services                                        PHC services in Malaysia, including for diabetes
The findings of the World Health Survey 2000                   management, asthma management, appropriate
instigated improvements in selected facets of the              hospitalisation, client-friendly clinic, pathology
Malaysian health care system to upgrade the                    services, radiology services, and pharmacy
delivery of services so as to be more responsive to            services.
patients’ expectations. However, increasing client                       An initiative to ensure the provision of
expectations has posed concerns on the health                  quality healthcare in health clinics is the
system’s responsiveness. The monitoring of                     improvement of the work process by developing
complaints through well-established channels                   practice standards and guides for credentialing and
(complaints boxes, media (email, telephone, verbal)            privileging of clinical staff, standard operating
to the Minister of Health and Director General                 procedures, and comprehensive guidebooks to
Health, the Chief Secretary of the Government and              guide the clinic staff on managing and coordinating
to the Bureau of Public Complaints in the Prime                the activities of the clinic, ranging from clinic
Minister’s Department) has shown that the                      administration, environmental sanitation to patient
community’s concerns with the responsiveness of                care.
the healthcare system remain. The majority are due
to lack of communication skills of the providers.              WAY FORWARD - 1CARE FOR
                                                               1MALAYSIA
Patient Safety                                                 As the country approaches developed status, as
Patient safety is addressed by ensuring competency             demographic and epidemiological transitions
of healthcare workers through practice standards,              continue, and as new technology expands the
legislation,    credentialing    and    privileging.           possibilities for intervention, the demand for health
Competency 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 of
health care system to meet the challenges posed by             sickness, not merely providing curative care to the
demographic & epidemiologic transition, higher                 sick. Leading the primary health care team
expectations of the population and escalating health           including allied health professionals and
care cost, the Ministry of Health has proposed                 paramedics as well as with NGOs and civil
1Care for 1Malaysia in 2009 - a restructuring of               societies in the communities, the PHCP provides
the country’s health care system to align it with              team-based care, especially for people with chronic
Malaysia’s aspiration to become a high income                  health conditions, leading to improvements in the
nation.                                                        management of chronic diseases, which accounts
                                                               for 40 to 70% of health care system costs. As
Target of Reform                                               experience in other countries has shown, the
The aim of health reform is to have one integrated             coordinator-of-care and gate-keeping role of the
national system where both the public and private              PHCP is facilitated by the financing mechanism
sectors have managed growth and the resources are              with payment by capitation with case-mix
optimally 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 additional
Healthcare Services & Facilities Act whose                     incentives for achieving performance targets and as
enforcement leaves much to be desired. With                    inducement for working in less desirable areas.
reform we want healthcare of better quality to be
provided by both sectors with common standards                 The PHC Health Delivery System
and equal monitoring. Universal access can be                  The patient will find it more convenient in the
improved with anybody who needs care being able                reformed system as he can choose the PHCP he
to receive it at their convenience. This is facilitated        wants to register with within the community either
by reform in healthcare financing and the attributes           in public or private sector. The first point of contact
of social health insurance in promoting social                 for the patient is the PHCP where they receive
justice and solidarity as well as financial                    treatment and then return home. If the patients need
sustainability, 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 seek
Everybody will contribute (mandatory inclusion)                treatment either in public or private hospitals. Upon
with a community-rated premium; the rich, young                completion of treatment, the patient will be
and healthy subsidising the poor, elderly and                  returned to the PHCP. Even though patients are
disabled, respectively. The government will                    registered with their PHCP, they still have a choice
continue its function of providing a social safety net         to seek treatment from other providers by paying
for the vulnerable groups by subsiding for their               OOP or through PHI. Primary health care reform
premium but the subsidy will be more targeted to               will increase opportunities to improve access to
those in need, unlike the present system where all,            primary health care physicians with innovative
rich and poor alike, benefit from universal                    appointment scheduling, shifts in physician work
government subsidy. Individuals still have a choice            hours, after-hours clinics and widespread
of 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 providers
have a choice to enter the system or not as they can           The Reformed MOH
still cater to this group of patients who pay out of           The MOH will be a leaner organization with very
pocket or who have private health insurance.                   highly specialized functions. It becomes more
                                                               technocratic and less bureaucratic. The primary
PHC – Thrust of 1Care                                          focus is governance and stewardship which
The thrust of this reformed health system is primary           includes policy and strategy formulation, evaluation
healthcare, 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 and
comprehensive and continuous care, no matter what              development will encompass aspects as standard
the 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 physical
conditions 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 MOH
from with the support available for his well being,            or an independent body depending on the authority
in short being cognisant of the broader determinants           and responsibility. A very important function now
of health, with links to public health. The PHCP               in MOH will be the monitoring and evaluation
looks 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 a
and 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            PHC
services mainly through the centre for disease                REFORM
control, research and other services. These services          Strengthening of the primary health care system is
will 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 with
authorities and MHDS. There will still be some                obstacles to continuity and coordination of care are
delivery of community health services, namely                 clearly identified and removed. A culture of
communicable disease control.                                 accountability, performance measurement, and
          Various functions of MOH will now be                quality improvement will support targeted funding
under several autonomous bodies such as Drug                  tied to expected outcome with governance and
Regulatory      Agency,      Health     Technology            funding models which support team-based care
Assessment and professional bodies such as MMC                needs to be strengthened. The important role played
and MDC.                                                      by the broader determinants of health is given due
                                                              recognition with links to public health services at
The Autonomous Healthcare Delivery System                     the district level.
The delivery of health care will be devolved to the
autonomous Malaysian Health Care Delivery                     Infrastructure support for PHC system
System (MHDS) comprising public and private                   The support needed include an adequate health
health care providers and this increased autonomy             infrastructure and an adequate supply of health
allows it to be more responsive to the population             human resource with the right skill mix to support a
health needs and expectations. The scope of                   team approach focused on patient needs. The
autonomy of the independent MOH-owned bodies                  existing primary health care team consists of the
is as not-for-profit organisations, accountable to the        physician, dentist, pharmacist, assistant medical
MOH and with independent management boards.                   officer, nurse, community nurse, medical laboratory
They manage their own budgets i.e. self                       technologist, assistant pharmacist, assistant
accounting, with the ability to hire and fire and with        environmental health officer, public health
the flexibility to engage and remunerate staff based          overseer, health attendant and clerical staff. Human
on capability and performance.                                resource development in 1Care encompasses all
          Health services will be purchased from              categories of healthcare personnel whether in
registered providers including independent Primary            primary or secondary/tertiary care. Appropriate
Health Care Providers (PHCP) which include                    training for health care personnel such as training in
primary care clinics, dentists and pharmacies.                management of public providers and managers in
Public hospitals will be coordinated on regional              preparation for greater autonomy has to be
networks and funded through a global budget based             conducted. The current general practitioners in
on case adjustments using DRG. Private hospitals              private practice will undergo a conversion to family
services will be paid through case-based payments.            medicine specialists and in the future, only family
Other payment mechanisms apply for dental and                 medicine specialists will be allowed to open a
pharmaceutical prescriptions where patients will              primary health care practice. The facilities will be
make some co-payments when receiving service.                 accredited and credentialing & privileging of
But identified population groups will be exempted             primary health care physicians will be
from these co-payments. Payment for services in               implemented.
the autonomous arms will be based on their
performance and fulfilment of the MOH                         ICT
specifications.                                               Information & communication technology is a pre-
                                                              requisite of the re-structured health system and the
Healthcare Financing                                          use of electronic medical records will increase
Funds will be managed by the new National Health              opportunities to improve continuity of care as well
Financing Authority that is publicly owned and                as develop the capacity for performance
operates as a not-for-profit institution. The National        management based on targets, coverage and key
Health Financing Authority (NHFA) will be                     performance indicators.
established to undertake the task of collection of                      Tele-primary care is one such system
SHI contributions, pooling of funds and                       which has been developed for primary care in
disbursement to healthcare providers. NHFA will               Malaysia and its implementation will need to be
also work out the formularies for premiums, pay for           hastened to facilitate health reform efforts. To
performance, unit costs/fees and benefits packages            support continuous access to health information and
in collaboration with MOH and MHDS. This                      advice, tele-health and myportal initiatives will be
reform 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 landmark
special 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 was
information 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 the
24-hours first-contact services to ensure continuity           primary health care model as the foundation of
of care information to be communicated to the                  health services, with its strong focus on preventing
patient’s regular care provider in addition to after-          illness or injury and promoting health. It recognises
hours visits.                                                  that various components of health care system are
                                                               interdependent and that the health care system's
Change management                                              quality and access problems cannot be dealt with
Given the scale of the restructuring, it is imperative         effectively unless we pay more attention to primary
that change is managed effectively at all levels of            health care. Lessons from other parts of the globe
stakeholders and explicit change management                    has argued that the primary health care approach
activities are needed to support all activities. While         best "facilitate the integrated management of
developing the blueprint, many more deliberations              multiple conditions, a continuum of care, the
with interested parties and stakeholders including             engagement of communities, the provision of care
the community will be undertaken. This is to ensure            close to home and prevention and health promotion
the 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 to
injection of investments particularly for the                  contribute to a sustainable and high performing
restructured public system in order to compete with            healthcare system which subsequently will have the
the private sector on similar footing.                         potential to impact on the health of Malaysians.
          A realistic time frame for phased
implementation is required to ensure that the
requisite manpower, infrastructure and ICT needs
and challenges are addressed. At the same time,
there will be better rationalisation of services as the
system improves equity and efficiency of service
delivery according to population needs. Some
facilities may relocate to capitalise on the
incentives provided in the restructured system and
responding to the bigger market of health care
buyers throughout Malaysia.

CONCLUSION
The Malaysian health system has performed well
over the years, compared to countries of similar
economic status, in building a system that produces
well-being at a low cost to society (Merican & bin
Yon 2002). The public system has not kept pace
with population growth, however, and the growth
of the private health sector means that people in
higher income groups enjoy quicker access to
private health care, while poorer people have no
choice but to rely on government services 7.
Disparities in health outcomes between population
groups and geographic areas have been reduced
although 3% of the population reported difficulty in
1996 in accessing health care mostly due to
distance and transport costs (NHMS II1996).
Additional expenditure thus is required to cover
needy population groups, especially in remote areas
where services are the hardest logistically and most
expensive per capita to provide. This is especially
pertinent for Sarawak where it has been a great
challenge to provide universal health care to the
“unreachable”, those staying in the remotest areas
of the state.



                                                          56

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Primary health care reform in 1 care for 1 malaysia

  • 1. International Journal of Public Health Research Special Issue 2011, pp (50-56) Primary Health Care Reform in 1CARE for 1 Malaysia Dr. Kamaliah Mohamad Noh Family Health Development Division, Ministry of Health Malaysia ABSTRACT element within primary health care that focuses on Primary 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 and care system while primary care is just one element personal care. within PHC that focuses on health care services. Healthcare services in PHC has a dual The present status of PHC in Malaysia and the function of directly providing services at point of strides it has made in uplifting the health status of first contact and a coordinating function to ensure the nation is described. The challenges that the continuity of care and ease of movement across the Malaysia 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 a and reforms in PHC will ensue in due course. The team of physicians, assistant medical officers concept 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 the aimed at addressing three main concerns on listing grows longer as the scope of services at PHC seamless integration of care especially for the becomes more comprehensive. management of chronic diseases, ensuring universal coverage and responsiveness of the health system in PRESENT HEALTH STATUS the face of increasing client expectations and The Malaysian PHC delivery system provides patient safety. The opportunity for macro reform to population-based services using a life-course improve the health of Malaysians by developing a approach in delivering services from womb to sustainable and high performing health care system tomb. The health of Malaysia’s population has is being seized by the Ministry of Health in 1Care. benefited from a well-developed primary health The micro reforms are discussed as regards to care system, together with improved access to clean increasing access to services, development of water and sanitation, and reinforced by programs to primary health care teams to deliver comprehensive reduce poverty, increase literacy, and build a PHC, the application of ICT, the renewed emphasis modern infrastructure. on health promotion & prevention activities and a Malaysia has made great gains in life renewed focus on community empowerment and expectancy for its people. Life expectancy at birth participation. Support in terms of human resource, rose between 1970 and 2008 for men from 61.6 to governance & funding models, capacity building in 71.6 years, and for women from 65.6 to 76.4 years monitoring & evaluation as well as change (Table 1): similar to the average life expectancy of management to affect the reforms are identified. 72 and 76 years for men and women respectively in The paper concludes with lessons learnt from other 2006 in the Western Pacific Region of the World countries and the importance of systemic reform for Health Organization. Infant mortality dropped a well functioning health delivery system. substantially between 1970 and 2008 from 39.4 to 6.4 deaths per 1000 live births: just above Australia INTRODUCTION 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 1.4 and a spectrum of services beyond the traditional to 0.3 deaths per 1000 live births. health care system while primary care is the Table 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
  • 2. 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 0.3 Source: Department of Statistics Malaysia, Time Series Data, Population Statistics, accessed at http://www.statistics.gov.my WHO World Health Statistics 2010 Although non-communicable diseases now reported in 2000 and 2004 but the rate declined account for most mortality and morbidity, thereafter to 1.2 per 100,000 (334 measles cases) in communicable disease continues to be a threat but 2008. Incidences of polio, diptheria, and whooping great progress has been made in the past decade in cough (pertussis) have been low for the past 20 prevention and control as shown in the downward years, and neonatal tetanus has been less than 1 per trends in Hepatitis B, measles, diptheria, neonatal 100,000 live births (Figure 1). Malaysia began its tentanus, pertussis and HIV, although dengue, national polio vaccination program in 1972, the last tuberculosis, and malaria remain concerns. Rates of polio outbreak occured in 1977, the last indigenous vaccine preventable diseases have dropped in wild poliovirus was reported in 1984, and no polio recent years in response to active vaccination cases were detected until 1992 when three imported programs with high rates of immunization cases were reported. Malaysia was certified as coverage. 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 (886 reported 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 to 1950s, 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 health clinic serving a population of 15,000 to 20,000 centres were amalgamated with hospitals. people and a rural clinic covering 2000 to 4000 population. The number of health facilities increased rapidly especially from seven health 51
  • 3. 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 inequity considerable 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 (the doctors 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 Healthcare THE NEED FOR REFORM System The challenges to health systems around the world The currently dichotomous healthcare system has are just as applicable here in Malaysia, namely to our healthcare resources spread between the private focus 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 the health (such as tobacco); universal access to patient receiving almost free primary healthcare healthcare services and investing in research & services and a largely subsidised secondary care development. services, while the private sector is fee for service with out of pocket payment or through private Health Challenges health insurance and employer payment. With the The challenges facing the Malaysian health system mismatch between the distribution of healthcare include 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 not public expectations; issues of economic optimally utilised. This is especially so in primary inefficiency in the targeting of limited health fund health care where the public sector has only about with 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 limited appraisal & reward systems for performance; Epidemiological Transition - Chronic Diseases conflicts of interest as the MOH is the funder, Chronic diseases are the major cause of death and provider and regulator of health services; disability in Malaysia, accounting for 71% of the accessibility & 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 of illness (haemodialysis, cancer therapy, transplants emphasis on health promotion and disease etc.) and the pattern of private spending for health prevention in the outpatient setting calls into overtaking 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 health there 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 be will rise even faster. Medical inflation is usually translated into high quality population-wide chronic higher than overall inflation. disease care to counter the challenge posed by the epidemic of chronic diseases. With these challenges Ensuring Equity in Health confronting the health system, there is a concern on Strong economic growth has allowed Malaysia to access to continuity of care with the various significantly reduce overall poverty levels but providers apparently working in silos, not only inequality, however, remains a challenge. The gap between the public and private sectors of our between rich and poor has widened and income dichotomous health system but also within the growth has been strong only for the top 20% of public sector, between facilities and across the Malaysian income earners. The bottom 40% of various disciplines. This is exemplified in the case households 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
  • 4. International Journal of Public Health Research Special Issue 2011, pp (50-56) Ensuring Universal Access basic training. Universities and training colleges Whilst we are grappling with the challenges offering training in medicine and health sciences brought about by epidemiologic and demographic have to achieve standards set by the Ministry of transition, there are still areas in the country with Higher Learning. The Malaysian Medical Council problems in accessing primary care services, (MMC) maintains standards of medical education particularly in rural and remote areas, but also in in the country as for their medical degrees to be urban centres where the lack of after-hours services recognized, the training institutions have to be often results in the use of emergency rooms for inspected by the MMC. All those who deliver non-urgent care. To meet the increasing demands of clinical services are mandated by Law to be the public, efforts have been made to extend the registered with their professional bodies, doctors operational hours of the public clinics, but with no with the Malaysian Medical Council (MMC), and supporting increase in human resource, this has physician assistants and nurses with their respective raised the providers’ concerns regarding their work professional Boards. The professional bodies self life balance. regulate the proficiency of their members through the setting of standards and enforcement of ethics Policies and implementation strategies have and codes of conduct. Legislation, both the Medical evolved with the changing needs of the population and Nursing Acts, amongst others are also in place and the growing capacity of the health system. In to prevent unqualified personnel from practising as 2010, health clinics delivering only curative care health care workers in substandard facilities. for minor ailments and minor procedures were set up in urban areas, strategically located in residential Quality Services areas for the urban middle class and poorer groups. The Ministry of Health has developed a culture of These Klinik 1Malaysia (K1M) are manned by quality care with recognition of initiatives at the assistant medical officers and nurses and offer ground level, through competitions for models of services from 10 am to 10 pm daily. The response good practice, quality control circles, innovation for has been so good that from that initial 50 that were solving local problems, as well as setting quality operationalised in 2010, another 28 have been standards nationwide, supported by the operationalised 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 the rural areas, buses and boats equipped as mobile quality of care, as part of the Quality Assurance clinics have been introduced at the end of 2010. Programme and Quality Management System by These differ from the traditional mobile clinics in tracking indicators of quality of care at the national that there are now doctors manning theses services level. The implementation of the nationwide quality and the clinics can be run in the vehicle itself. assurance programme of the Ministry of Health since 1994 has set quality standards to ensure Rising Expectations attainment of service goals. More recently (2000), clinic–specific quality standards have been set for Person-Centred Services PHC services in Malaysia, including for diabetes The findings of the World Health Survey 2000 management, asthma management, appropriate instigated improvements in selected facets of the hospitalisation, client-friendly clinic, pathology Malaysian health care system to upgrade the services, radiology services, and pharmacy delivery of services so as to be more responsive to services. patients’ expectations. However, increasing client An initiative to ensure the provision of expectations has posed concerns on the health quality healthcare in health clinics is the system’s responsiveness. The monitoring of improvement of the work process by developing complaints through well-established channels practice standards and guides for credentialing and (complaints boxes, media (email, telephone, verbal) privileging of clinical staff, standard operating to the Minister of Health and Director General procedures, and comprehensive guidebooks to Health, the Chief Secretary of the Government and guide the clinic staff on managing and coordinating to the Bureau of Public Complaints in the Prime the activities of the clinic, ranging from clinic Minister’s Department) has shown that the administration, environmental sanitation to patient community’s concerns with the responsiveness of care. the healthcare system remain. The majority are due to lack of communication skills of the providers. WAY FORWARD - 1CARE FOR 1MALAYSIA Patient Safety As the country approaches developed status, as Patient safety is addressed by ensuring competency demographic and epidemiological transitions of healthcare workers through practice standards, continue, and as new technology expands the legislation, credentialing and privileging. possibilities for intervention, the demand for health Competency of health care workers starts with care by the population will continue to rise, putting 53
  • 5. 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 of health care system to meet the challenges posed by sickness, not merely providing curative care to the demographic & epidemiologic transition, higher sick. Leading the primary health care team expectations of the population and escalating health including allied health professionals and care cost, the Ministry of Health has proposed paramedics as well as with NGOs and civil 1Care for 1Malaysia in 2009 - a restructuring of societies in the communities, the PHCP provides the country’s health care system to align it with team-based care, especially for people with chronic Malaysia’s aspiration to become a high income health conditions, leading to improvements in the nation. management of chronic diseases, which accounts for 40 to 70% of health care system costs. As Target of Reform experience in other countries has shown, the The aim of health reform is to have one integrated coordinator-of-care and gate-keeping role of the national system where both the public and private PHCP is facilitated by the financing mechanism sectors have managed growth and the resources are with payment by capitation with case-mix optimally 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 additional Healthcare Services & Facilities Act whose incentives for achieving performance targets and as enforcement leaves much to be desired. With inducement for working in less desirable areas. reform we want healthcare of better quality to be provided by both sectors with common standards The PHC Health Delivery System and equal monitoring. Universal access can be The patient will find it more convenient in the improved with anybody who needs care being able reformed system as he can choose the PHCP he to receive it at their convenience. This is facilitated wants to register with within the community either by reform in healthcare financing and the attributes in public or private sector. The first point of contact of social health insurance in promoting social for the patient is the PHCP where they receive justice and solidarity as well as financial treatment and then return home. If the patients need sustainability, 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 seek Everybody will contribute (mandatory inclusion) treatment either in public or private hospitals. Upon with a community-rated premium; the rich, young completion of treatment, the patient will be and healthy subsidising the poor, elderly and returned to the PHCP. Even though patients are disabled, respectively. The government will registered with their PHCP, they still have a choice continue its function of providing a social safety net to seek treatment from other providers by paying for the vulnerable groups by subsiding for their OOP or through PHI. Primary health care reform premium but the subsidy will be more targeted to will increase opportunities to improve access to those in need, unlike the present system where all, primary health care physicians with innovative rich and poor alike, benefit from universal appointment scheduling, shifts in physician work government subsidy. Individuals still have a choice hours, after-hours clinics and widespread of 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 providers have a choice to enter the system or not as they can The Reformed MOH still cater to this group of patients who pay out of The MOH will be a leaner organization with very pocket or who have private health insurance. highly specialized functions. It becomes more technocratic and less bureaucratic. The primary PHC – Thrust of 1Care focus is governance and stewardship which The thrust of this reformed health system is primary includes policy and strategy formulation, evaluation healthcare, 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 and comprehensive and continuous care, no matter what development will encompass aspects as standard the 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 physical conditions 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 MOH from with the support available for his well being, or an independent body depending on the authority in short being cognisant of the broader determinants and responsibility. A very important function now of health, with links to public health. The PHCP in MOH will be the monitoring and evaluation looks at the full spectrum of disease, intervening (M&E) to ensure that the autonomous arms of 54
  • 6. International Journal of Public Health Research Special Issue 2011, pp (50-56) MOH function according to their specified tasks dichotomous healthcare delivery system with a and 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 PHC services mainly through the centre for disease REFORM control, research and other services. These services Strengthening of the primary health care system is will 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 with authorities and MHDS. There will still be some obstacles to continuity and coordination of care are delivery of community health services, namely clearly identified and removed. A culture of communicable disease control. accountability, performance measurement, and Various functions of MOH will now be quality improvement will support targeted funding under several autonomous bodies such as Drug tied to expected outcome with governance and Regulatory Agency, Health Technology funding models which support team-based care Assessment and professional bodies such as MMC needs to be strengthened. The important role played and MDC. by the broader determinants of health is given due recognition with links to public health services at The Autonomous Healthcare Delivery System the district level. The delivery of health care will be devolved to the autonomous Malaysian Health Care Delivery Infrastructure support for PHC system System (MHDS) comprising public and private The support needed include an adequate health health care providers and this increased autonomy infrastructure and an adequate supply of health allows it to be more responsive to the population human resource with the right skill mix to support a health needs and expectations. The scope of team approach focused on patient needs. The autonomy of the independent MOH-owned bodies existing primary health care team consists of the is as not-for-profit organisations, accountable to the physician, dentist, pharmacist, assistant medical MOH and with independent management boards. officer, nurse, community nurse, medical laboratory They manage their own budgets i.e. self technologist, assistant pharmacist, assistant accounting, with the ability to hire and fire and with environmental health officer, public health the flexibility to engage and remunerate staff based overseer, health attendant and clerical staff. Human on capability and performance. resource development in 1Care encompasses all Health services will be purchased from categories of healthcare personnel whether in registered providers including independent Primary primary or secondary/tertiary care. Appropriate Health Care Providers (PHCP) which include training for health care personnel such as training in primary care clinics, dentists and pharmacies. management of public providers and managers in Public hospitals will be coordinated on regional preparation for greater autonomy has to be networks and funded through a global budget based conducted. The current general practitioners in on case adjustments using DRG. Private hospitals private practice will undergo a conversion to family services will be paid through case-based payments. medicine specialists and in the future, only family Other payment mechanisms apply for dental and medicine specialists will be allowed to open a pharmaceutical prescriptions where patients will primary health care practice. The facilities will be make some co-payments when receiving service. accredited and credentialing & privileging of But identified population groups will be exempted primary health care physicians will be from these co-payments. Payment for services in implemented. the autonomous arms will be based on their performance and fulfilment of the MOH ICT specifications. Information & communication technology is a pre- requisite of the re-structured health system and the Healthcare Financing use of electronic medical records will increase Funds will be managed by the new National Health opportunities to improve continuity of care as well Financing Authority that is publicly owned and as develop the capacity for performance operates as a not-for-profit institution. The National management based on targets, coverage and key Health Financing Authority (NHFA) will be performance indicators. established to undertake the task of collection of Tele-primary care is one such system SHI contributions, pooling of funds and which has been developed for primary care in disbursement to healthcare providers. NHFA will Malaysia and its implementation will need to be also work out the formularies for premiums, pay for hastened to facilitate health reform efforts. To performance, unit costs/fees and benefits packages support continuous access to health information and in collaboration with MOH and MHDS. This advice, tele-health and myportal initiatives will be reform allows for integration of the presently used, especially during travel. There are areas in the 55
  • 7. 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 landmark special 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 was information 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 the 24-hours first-contact services to ensure continuity primary health care model as the foundation of of care information to be communicated to the health services, with its strong focus on preventing patient’s regular care provider in addition to after- illness or injury and promoting health. It recognises hours visits. that various components of health care system are interdependent and that the health care system's Change management quality and access problems cannot be dealt with Given the scale of the restructuring, it is imperative effectively unless we pay more attention to primary that change is managed effectively at all levels of health care. Lessons from other parts of the globe stakeholders and explicit change management has argued that the primary health care approach activities are needed to support all activities. While best "facilitate the integrated management of developing the blueprint, many more deliberations multiple conditions, a continuum of care, the with interested parties and stakeholders including engagement of communities, the provision of care the community will be undertaken. This is to ensure close to home and prevention and health promotion the 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 to injection of investments particularly for the contribute to a sustainable and high performing restructured public system in order to compete with healthcare system which subsequently will have the the private sector on similar footing. potential to impact on the health of Malaysians. A realistic time frame for phased implementation is required to ensure that the requisite manpower, infrastructure and ICT needs and challenges are addressed. At the same time, there will be better rationalisation of services as the system improves equity and efficiency of service delivery according to population needs. Some facilities may relocate to capitalise on the incentives provided in the restructured system and responding to the bigger market of health care buyers throughout Malaysia. CONCLUSION The Malaysian health system has performed well over the years, compared to countries of similar economic status, in building a system that produces well-being at a low cost to society (Merican & bin Yon 2002). The public system has not kept pace with population growth, however, and the growth of the private health sector means that people in higher income groups enjoy quicker access to private health care, while poorer people have no choice but to rely on government services 7. Disparities in health outcomes between population groups and geographic areas have been reduced although 3% of the population reported difficulty in 1996 in accessing health care mostly due to distance and transport costs (NHMS II1996). Additional expenditure thus is required to cover needy population groups, especially in remote areas where services are the hardest logistically and most expensive per capita to provide. This is especially pertinent for Sarawak where it has been a great challenge to provide universal health care to the “unreachable”, those staying in the remotest areas of the state. 56