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A Review of Primary Health Care in Malaysia
A Report for the World Health Organization Western Pacific Region
Dr N arimah Awin Director
Division of Family Health Development Ministry of Health
This report was commissioned by the World Health Organization, and is strictly confidential to the World Health Organization. The findings, interpretations and conclusions expressed in this report are those of the author and do not necessarily reflect the policy or views of the World Health Organization or the relevant Member State. While efforts have been made to ensure factual accuracy of the information contained herein, readers wishing to use this information are urged to contact the relevant Member State for the latest official information or views on any particular aspect related to this report. This report should not be referenced or quoted.
The designations employed and the presentation of the material in this report do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products or services does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned.
REVIEW OF PRIMARY HEALTH CARE IN MALAYSIA
11. EXECUTIVE SUMMARy)
An overriding policy in Malaysia is that Primary Health Care (PHC) shall be the thrust and foundation of the total health system. Based on this clear policy, the health care system in Malaysia continuously makes efforts to achieve equity in health and health care, encourages intersectoral collaboration and community participation, and provides a basic package of services that is to be delivered to all. The PHe is also linked to the other levels of care in the system, as well to the other PHe players in the country. There are many players, besides the Ministry of Health in the Malaysian PHC, both as formal providers (such as the fast expanding private care) and the informal providers (such as the many types of traditional and complementary health systems).
The development of PHC in Malaysia has encompassed policy formulation, infrastructure and manpower, sustainable financing, and a health management and information system development. In addition to this, the scope of the basic package of care has expanded to meet changing needs, priorities and capabilities, as exemplified by the newer activities for adolescent health, elderly health, community mental health, non-communicable disease control, food safety and workers' health. One of the more recent major developments in PHC in many countries including Malaysia is the need for health reforms, and how these will impact on PRe. The achievement of PHe can be measured by several effectiveness, health impact and efficiency measures. More recently, this has been added by quality measures as well.
There are, however, many challenges to the success ofPHC and these include issues related to responding to changing consumers' perceptions and expectations, the external environment such as environmental and socio-economic changes as well as population aging, the rapid pace of advancement in both medical and information-communication technologies, and globalization. Many of these challenges are also opportunities for a better health care to the population, such as the optimal use ofinfonnation technology as an enabler for better equity and quality ofPRC.
As one of the main principles ofPHC, community participation has been given due emphasis. There are several examples of community development projects at PRe level, and two of these are described in detail in this report, one each in the states of Sabah and Sarawak, where difficult access has made such community development projects very relevant and useful.
Many lessons are learned from the experience of Malaysia in developing its PRC system, either from the successes or from the challenges. There is a clear role of WHO and other international organizations in enhancing the further development ofPRC in the country by providing resources and expertise, and by being the agent or "broker" for countries to avail of resources and expertise, as well as being the single most effective international body for all aspects of health.
12. TABLE OF CONTENTSI
1. Executive Summary
2. Table of Contents
4.1. Policy on the definition and concept ofPHC
4.2. Health and health-related policies
4.3. Health planning
4.4. Coordination and partnership
4.5. Governance, legislation and other enabling instruments
4.6. Health reforms and their implications on PHC
Ci 5. Development of PHC
5.2. Physical infrastructure
5.3. Scope and content of services
5.4. Human resource
5.5, Financing and budgeting system
5.6. Health management and information system
5.7. Streamlining PHC and improving integration / referral system
5.8. Improving quality
5.9. Optimizing medical and information technology
5.10. Harnessing traditional and complementary medicine
6. Challenges o
6.1. The consumers of PHC
6.2. The external environment
6.3. Advances in medical and information-communication technologies
6.4. PHC and the wider world - globalization and the new world order
7. Health impact
7.1. Health service utilization
7.2. Impact and outcome on health status
7.3. Other impact
8. Community development approaches
8.1. The Village Health Promoter of Sarawak
8.2. The PHC Volunteer of Sa bah
8.3. Other community participation approaches
9. WHO and other organizations
10. References and bibliography
When the historical conference was held at Alma Ata in 1978 to address the gross inequities in health for the populations of the world, the ambitious goal of "Health For All By The Year 2000" was thought to be achievable by the Primary Health Care (PHC) approach. Unfortunately for many peoples of the world today, this has not been achieved, and health for all has to he seen as a "timeless ideal", or at best, as "health for all in the twenty-first century". Twenty-three years after Alma Ata, a review of PHC in countries of the world, including Malaysia, will be beneficial. This is especially so in the light of health care reforms that maI1Y countries, including Malaysia, will need to undergo, to ensure that such reforms not only promise continued sustainability of the PHC system, but also improve its quality.
4.1. Policy on the concepts and definitions of Primary Health Care (PHC)
One of the major policy statements of the health system in Malaysia is that health care shall he driven by and based upon Primary Health Care. PHC then is the foundation upon which the total health care is built. The term "Primary Health Care (PHC)" is taken to mean the philosophy and approach/vehicle to achieve health for all as defined by the Alma Ata conference. Inherent in this broad definition are the principles ofPHC as well as the concept of the basic package of service. It also can refer to the simple meaning of a level of care, but generally for this connotation, the term "Primary Care" is used. Therefore, Malaysia accepts and implements PHC as defined at Alma Ata:
It is also the first level of contact of individuals, the family and community with the national health system, bringing health care as close as possible to where people live and work, and constitutes the first element of a continuing health care process
Primary Health Care is essential health care based on practical, scientifically sound and SOcially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination. It forms an integral part both of the country's health system, of which it is the central function and main focus, and of the overall social and economic development of the community.
4.2. Health and health related policies
The WHO defines a health policy as "a set of decisions to pursue courses of action aimed at achieving defined goals for improving the health situation ". While there is no single "health policy" in Malaysia, the Ministry of Health has enunciated several policy statements, and foremost in these policies is 'Primary Health Care shall be the foundation and engine of the country's health care system"
One of the clearest reasons for the relative success of the Malaysian PHC and overall health systems is the priority given to those who are considered "disadvantaged". These include poor and rural communities, and PRC was therefore concentrated for these communities. This propoor policy has brought about dividends in terms of health and socio-economic development to the people of Malaysia.
Another major policy of health care in Malaysia that is ensured by PHC is that of equity. The development of health facilities such as PRC outlets ensures "availability". However availability must ensure "access", which is the utilization of these facilities by the people. Then there is also the need to ensure "equity" and this connotes that different needs must be met differently, according to the degree ofthese needs. Up till now, PHC is the best vehicle to ensure not only availability and access, but also equity.
To guide these policies for health, the Ministry of Health has developed and disseminated the Vision For Health to be adopted by all health care providers, with a Mission Statement for the Ministry of Health itself. Over-riding all these instruments is the national vision to enable the country to achieve a fully developed status by the year 2020. To complement these macro policy statements, the Ministry of Health in the current SUI Malaysia Plan also has enunciated the eight (S) Health Services Goals, all of which have relevance to PRe. Annex 1 shows the National Vision for 2020, the Vision for Health, the Mission of the Ministry of Health and the eight Health Service Goals.
Besides overriding policy statements there are also policies on specific health issues. For example there are policies on elderly health care, health of adolescents, mental health, etc. Some of these; like the policy on elderly or the policy on women, take the form of an overall national policy, in which health is one of the sectors being addressed. Needless to say, many of these policies are not entirely within the Ministry of Health, nor indeed within health sector alone. These are made with intersectoral inputs and in line with the principle of "healthy public policies" in health promotion.
4.3. PHC in health planning
Health planning at the macro level is carried out as part of national development, and is an integral component of the Five Year Development plans and the longer-term outline perspective plans (OPP) of the government. In all these high level policies and plans, PHC is given importance, as it is the foundation of the health care system. To illustrate this, the objectives of the Ministry of Health for the current 5-year plan (the Sth Malaysia Plan spanning 2001 -2005) emphasize PHC (Annex 2). In terms of planning for facilities, PHC has been enjoying a high priority. During the 2nd and 3rd Malaysia (1971 - 19S0) Plan, the PRC system was transformed from the three-tier to the two-tier system which is accompanied by improvements in many aspects of health care delivery. Besides ensuring access and equity, such restructuring also led to better quality of care. There has been a gradual and clear increase in the number of health facilities closest to the community in the form ofPHC service outlets. Besides this improvement in numbers and therefore in improving availability, accessibility and equity, there has also been an improvement in the design of these facilities to cater for the wider scope of services and improved quality ofPHC. This expansion of service scope is described in section 5 under the development of PHC in the country.
4. 4. Health sector coordination and intersectoral partnership
While the planning and policy making processes described above are centered in and coordinated by the Ministry of Health, they allow for and encourage the participation of all agencies directly or indirectly related to health and health care. There are various coordination mechanisms between the Ministry of Health and the other government and non-government agencies. The involvement of the other sectors in policy formulation is direct and deliberate, and this is achieved through the preparation of the Five Year Development Plan, and its midterm review, to which the Ministry of Health invites the other relevant sectors, both public and private. There is also the Inter Agency Planning Group (IAPG) at the Prime Minister's Department. This is a high level policy making body at which matters related to PHC can be presented and discussed. There are, in addition, the various inter-agency committees (some at Cabinet Minister's level) for specific issues e.g. for zoonotic disease, for HNIAIDS, for food safety, for nutrition, for school health, adolescent health, elderly health etc. The Ministry of Health conducts an annual dialogue session with other government agencies, professional bodies, health-related industries and NGO's at which issues are raised and discussed.
At PHC level, besides the collaboration with government agencies, there is also involvement of the community and civil society. The mechanisms for this include the visiting board of the hospitals, the advisory panel of the health clinics, and the village development committees. One of the more recent and successful initiatives in PHC through intersectoral partnership is the Healthy City Project, for which the two first projects in Kucing and Johor Baru are considered successful. From this initial success, many more healthy settings projects have been developed in Malaysia.
4.5. Governance, legislation and other enabling instruments for PHC
Governance is a very important concept in health care and in the "bottom-up" approach, governance begins at PHe level. It encompasses the mandates for the core businesses in health care, and these include health leadership, fair and effective regulation and overall responsibility for compliance, accountability and transparency, the effective participation of civil society and access to knowledge, information and education.
For some of the components ofPHC, there are clear mandates and instruments in the form of direct legislation (e.g. disease control, tobacco control, food safety). In some others the legislation may be less direct and are enforced by agencies other than the Ministry of Health. For example, there is legal age for marriage to avoid teenage pregnancies, the domestic violence act, and the drug laws to curb substance abuse. In some areas, there are other instruments such as codes of ethics and codes of practice, such as the Code of Ethics for the Marketing ofInfant Formula Products. Besides these local mandates and instruments, Malaysia also endorses and enforces several international conventions and agreements, such as the Declaration of Rights of the Child, the Convention on Elimination of All Forms of Discrimination Against Women, etc, which are accordingly implemented at PHe wherever relevant.
4.6. Health reforms and their implications 011 PHC
The term "health reform" most often refers to structural and financial changes. However, if reform is seen to encompass the other various intentional changes such as process re-engineering, quality improvement, service reorientation, then there are several examples in Malaysia. There are also other reforms in PRC in the adoption of newer paradigms such as those in the WHO (WPRO) initiative "The New Horizons in Health", as well as in the "New" Public Health. A
feature of health reform that has relevance to PRC is the commitment to transparency, accountability, participation, and access to knowledge and information, which reinforces good governance and stewardship.
The current centralized health system in Malaysia has performed creditably well in making health care accessible to a vast majority of the population. This system has proven to be socially just and efficient, and is politically very acceptable. However there may arise compelling reasons to question the continued viability of this system, and reform may be inevitable. Spiraling health care costs have been much discussed as an impetus for alternative financing systems, and there is the growth of the private sector which can and should be optimized. The community has matured and is reckoned to be ready to take up more responsibility for its own health care including cost sharing.
Options for major structural reforms, unavoidably linked to health financing are being discussed. The structural reform is mainly on decentralization, which may take several forms, i.e. delegation, deconcentration, devolution and deregulation; which may involve privatization and its less radical variant, corporitisation. There will be the inevitable financial re-arrangements as well with respect to cost sharing, and as mentioned in the preceding paragraph, Malaysians are now in a position to share health care costs. The approach will be appropriate to the country and will probably in the form of a social insurance that will have a built-in protection mechanism for the poor.
In whatever form the refom1 will take, a basic principle is the protection of essential public health functions and the basic package ofPHC services, so that equity is not compromised in any way. Also, any reform will need to ensure that the quality of services remain acceptable to the community, so that they will not find it tempting to use the higher level of care ("bypassing" of PRC, which is described in Section 5.2) which is more likely to cost more. In other words, health reform must protect PRe and that the community will optimally use PRC so that it becomes an effective "gatekeeper" in the health, not just to contain cost but to provide the most appropriate care.
In essence, PRC is to be a very important consideration in whatever reforms are being undertaken in any health system. This is clearly enunciated in the Ljubljana Chater on Reforming Health Care 1996. This charter requires that health reforms are to be based on the principle that health care should lead to better health and quality of life for the people, with targets for health gains and oriented towards PRC The government shall continue to exercise its responsibility to assure
access, equity and quality care. .
15. DEVELOPMENT OF PRd
There are many health care providers in the country, both formal and informal. The Ministry of Health is by far the major provider in the formal sector providing access for almost every individual. The other government providers are the teaching hospitals of the medical schools under the Ministry of Education, the Ministry of Defense, the local governments, and the Department of Aborigines Affairs. The private sector is a fast growing industry in the urban areas, consisting of clinics, managed care organizations and hospitals. However they provide
sector, traditional and complementary health and medicine (T/CM), mainly ethnic-based, are used by a large section of the population. With the current policy to integrate and encourage T/CM, this will grow further. There are also health services byNGO's but these are even more limited, meeting specific needs, such as halfway homes for battered women, cancer respite and hospice care.
In 1978, the health infrastructure in Malaysia as provided by the Ministry of Health was already relatively well developed. The PHC service outlet in the rural areas was the Health Centre, which provided, even by then, all the eight elements of basic health care. In the urban areas, primary care was mainly for curative care provided by outpatient clinics of hospitals and polyclinics, with care for mothers and children provided by maternal and child health clinics. The rural Health Centre is now termed the Health Clinic and is still the service point for PHe. Many of these are in areas that now have become urbanized. At that time, there was very little private care, which today has grown significantly, but still providing mainly curative primary care, and are still mainly in urban areas.
In 1978, the health system in Malaysia was already practicing the basic principles ofPHC. These are equitable, universal and affordable health care consisting of a basic package of essential care, community participation, intersectoral cooperation and appropriate technology use. Efforts are continuously made to strengthen these. All the eight elements of the basic package were already being provided in these Health Clinics, and these are, health education, adequate food supply and proper nutrition, maternal and child health, child immunization, prevention and control of endemic diseases, safe water and sanitation, and treatment of diseases with provision of essential drugs. There was and still is, a ninth element, dental care. Since then, the scope and content of PHC have undergone expansion to include newer areas of concern, such as women's health, community mental health, health of older persons, etc. Thus, it can be claimed that Malaysia adopted the comprehensive rather than the selective model of PHC.
5.2. Physical infrastructure
Under the Ministry of Health there are the 13 State Health Departments, and in each state there are varying numbers of District Health Office, totaling 106 in the country. Under the district health authority there is the two-tier PHC system. The first tier is the Health Centre/Clinic as the first tier which provides all the eight basic elements ofPHC (and the newer expanded scope of activities). The second tier is the Community Clinic (used to be called the Village Clinic or Klinik Desa) which provides only three elements (maternal health, child health, and treatment of minor ailments). Please see Annex 3 and Annex 4. Upto the 1970's, PRC in Malaysia existed within the thee-tier system. The conversion to the two-tier was to improve quality of care at the lowest level of care.
Malaysia has a very good access by the population to PRC facilities. The norm for these facilities is one PHC clinic for 15,000 to 20,000 population, and one community clinic for 5,000 population. These targets have been met. From the Second National Health and Morbidity Survey in 1996, 88.5% of the population live within 5 k111 ofa health facility and 81% live within 3 km. For the population with less physical access, outreach services continue to be given by the Ministry of Health such as mobile clinics and the flying doctor service in Sabah and Sarawak, and in the more remote areas in Peninsular Malaysia. As of December 2000, there were 843 health clinics, 1,924 community clinics, 104 MCH clinics and 204 mobile health teams. Please see Annex 5 for the distribution of facilities
The PHC service points have expanded its scope of services to more than the basic eight essential services. This expansion has implications on the health infrastructure at PHC, such as newer designs and bigger space. For examples, there are the low risk birthing centers to allow low risk mothers to deliver her baby instead of in the less congenial home environment. There is also the radiology service, as well as rehabilitation rooms and equipment for the elderly and disabled and counseling rooms for the adolescents. In some clinics, space is provided for psycho-social rehabilitation of mental patients.
Several community-based facilities have been developed, and some are in partnership with related agencies and the community itself, such as the CBR (Community-based Rehabilitation) Centres for children with special needs. Besides the low risk birthing centers at health clinics, there are also now and alternative birthing centers attached to hospitals, as well as ambulatory care centers to decentralize care from hospitals.
PHe cannot exist in isolation. It is linked to secondary care, provided by a system of hospitals, which range from fairly big state hospitals with a full range of specialist services to smaller district hospitals. There is a well-established referral from PRC to secondary care and this is continually improved and strengthened, especially with the Ministry of Health placing emphasis on integration. Besides this "vertical" integration within the facilities of the Ministry of Health, there is a strong policy to enhance "horizontal" integration with the other health care providers including the private sector, to ensure continuous and seamless care.
One of the inherent weaknesses ofPHC is the possibility of it being by-passed by the community, who for some reasons prefer to use the higher levels of care, when there is no necessity to do so. In Malaysia, the by-passing of the health clinics to avail of the nearest hospital does occur. From the Second National Health and Morbidity Survey (1996), it was seen that 39.6% of the respondents by-passed the nearest health clinic. Of these people who by-passed, 72.5% went to a private clinic, 14.2% to the district hospital, 6.5% to the state hospital and 2.9% to a traditional healer. The main reasons for by-passing were waiting time, availability of a specific doctor and appropriateness of treatment. Only a small proportion of the respondents cited the attitude and behaviour of the health care providers was cited as a reason for by-passing the PHC facilities.
5.3 Scope and content of PHC services
PHC when first formally introduced in 1978, required the basic package of eight essential care to be made available to every individual, The extent and comprehensiveness of each of these would have differed form country to country depending on comparative needs and resources available. For example, the element of "MCH including family planning" has expanded to encompass women's health, both reproductive and non-reproductive. The PRe now also has service for older persons, adolescents, and children with special needs. Child immunization has expanded to include newer antigens to protect children against diseases that were not included before in the EPI, such as rubella and viral hepatitis B. Prevention and control oflocally endemic diseases has expanded to encompass non-infectious and chronic diseases such as heart diseases, hypertension, diabetes, cancer and non-intentional injuries. Worker's health has begun to be implemented at PHC levels in many urban places. There is also a plan underway to put in place a population risk screening strategy so that prevention is more effective. Mental health is also now being incooperated into PHC.
5.4 Human resource
PHC providers in Malaysia consist of health workers who are multi-disclipinary in nature, have the required range and level of competencies, and as far as possible, are supplied in adequate numbers. This last criterion is the one that is most challenging. The Ministry of Health is one of the largest public organizations in terms of the number and types of personnel it employs. There are more than 100,000 positions in the Ministry of Health organizations at all levels, and they consist of a wide variety of professionals, para-professionals and support staff.
At PHC level, the staffing is determined by the scope of services provided. To enable all the eight basic elements to be given, a PHC clinic is managed by one or more doctor, a dentist, and a variable number of allied health workers or para-medics depending on the population and the health problems. These include medical assistants, public health nurses, assistant nurses, community nurses, dental nurses, dental assistants, midwives, public health inspectors, assistant pharmacists, medical laboratory technicians, public health overseers, ambulance drivers, and patient attendants. A radiographer is placed in some of the outlets that have x-ray facilities. The recent addition of the Family Medicine Specialist or physician is a positive move towards improving quality of care.
Besides their number and category, the PHC staff is of required competence and professional standards including being patient-centered in their values and behaviour. Thus the PHC staff continually up-grade their knowledge and skills, and at the same time, instilled with the right values and attitudes. A current issue that is threatening PRC in Malaysia is the number of health workers and to some extent their distribution. While the numbers have steadily increased over the years, it is still not adequate to cater for all the newer and expanded scope of PHC services and the improvement in quality as a response to increasing demands and expectations of the consumers.
Annex 6 shows the number of some of the health workers in Malaysia, distributed in the public and private sectors. Unfortunately, it is not easy to differentiate them by level of care. However, with the policy of ensuring as much as possible for the fair and rational distribution of health human resource, PHC is provided with a fair proportion of these health workers.
5.5 Financial and budgeting system
The main source of financing for health care services is from public revenues through general taxation. Public health services, which encompass almost all of PHC are provided fee to the users of the public health system. Health funds therefore are directly procured from the federal budget, In this centralized system, the financial and control system is not very flexible compared to other funding sources such as local revenues or grants. But it allows for security and PHC does get a fair amount from the national health budget. Also fairness in financing is assured by the needsbased formula for determining allocation, using parameters such as population size, socioeconomic conditions, burden of illness (or health status) and private sector access.
The total federal budget amounts to about RM 50 billion (Malaysian ringgit, currently pegged at RM 3.8 to the US dollar) annually. Out of this total federal budget, about 7% RM 4 billion is for health. The amount for the PRC component cannot be ascertained with accuracy, but a reasonable representation is the allocation for the Public Health Programme which is between 18% to 20% of the health budget. This amounts to about RM 700 million annually. Out of this allocation, most of it contribute to PHC through any of the five Public Health activities - Family Health Development, Disease Control, Health Education, Oral and Dental Health and Food
Quality Control. Please see Annex 7. There are separate funds for another major PHC activity, environmental health and sanitation, and this amounts to between Rlvl 18 million to Rlvl 20 million annually.
There is also funding obtained from international organizations. The WHO regularly gives support in the form of consultants, fellowships and attachments. There is also funding from other agencies such as UNICEF, UNDP, UNFPA and others.
5.6 Health management and information system
One of the requirements for a PHC system to function well is a reliable health information system, that only can give information on the health situation, but also one that can track the performance of PHC over time and allows for improvements and remedial actions to be taken. The Ministry of Health had from the early 1970's developed a Health Management Information System (HMIS) that has undergone several reviews. This system allows for PHC activities to be assessed. In view of the holistic nature of the inputs into PHe especially with the multi-sectoral determinants of health, the system uses indicators that cover other sectors. This format is used for the Common Framework of Monitoring (CFM) and Common Framework of Evaluation (CFE) by WHO. There are four classes of these indicators, i.e. socio and socio-economic, health status, specific health problems and health service improvement (See Annex 8).
The changing scenario and the responses ofPHC require a constant review of the HMIS. The system is now being designed to allow for sharing across all stakeholders and providers of health care. It also wi11look into a better and more compliant reporting by the private sector to the Ministry of Health on important issues. For instance, there is still the problem of getting adequate and timely information form the private sector for coverage of services such as immunization, Pap's smear and family planning. There is also unsatisfactory compliance in the notification of infectious diseases. Another weakness of the HMIS is the absence of gender-segregated data.
The review of the HMIS shall also look into the collection of gender-segregated data such as for morbidity and mortality rates to allow for more effective gender analysis. This is becoming increasingly important to facilitate planning for more gender sensitive and women-friendly PHC services and for mainstreaming gender into health policies.
5.7 Streamlining PHC and improving integration/referral system
Up to the early 1990's, primary medical (curative) care or outpatient care by the Ministry of Health was delivered by two different programmes for urban and rural populations. For the rural areas, outpatient care was provided by the health clinic, and if further care is needed the patient is referred to the nearest hospital. The urban communities had access to outpatient care in the hospitals themselves, and polyclinics, besides those in the private sector. To ensure adequate emphasis is given to PRC, outpatient services i.e. curative care (primary medical care) was transferred from the domain of secondary (hospital) care to that of public health, to the Family Health Development which is responsible for PHC. By this, there is now a merging of primary medical care into the ambit of primary health care. More significantly, by this policy the elements of promotive and preventive care can be better linked with curative care, facilitating the transformation of the focus of the health system from the illness to the wellness paradigm. This uniformised the approach and quality of care for urban and rural areas, since it allowed for policies related to outpatient care be under one management. There is for instance a more rational distribution of resources between urban and rural services.
The above streamlining, along with the placement of Family Medicine Specialists has to a large extent strengthened the referral system. This has improved vertical integration within the different levels of care in the Ministry of Health making PHC an effective "gatekeeper" in the system. The referral system is reviewed and improved upon from time to time. The integration with the other health systems such as the private sector and the traditional and complementary systems still need much improvement. However, with the eight Health Services Goals adopted for the health sector, there are better opportunities and mechanisms for horizontal integration between the various providers ofPHC, in a more seamless, continuous and integrated system. Besides integration of levels of care and providers of care, there is also integration of activities within PHC. For example in 1978 there were three vertical disease control programmes, for malaria, TB and leprosy. Now these have been fully integrated into the PHC system. Family planning services in the rural areas are integrated into the PHC
5.8 Improving quality
The Malaysian health care system including PHC has made significant strides in quality improvement, whether in terms of general quality efforts, or in technology and equipment or in human resources for PHC. The Ministry of Health has emphasized quality since the 1980's. While the Quality Assurance Programme (QAP) was first introduced in the hospitals in 1985, the PHC began it slightly later in 1989. Since then, the number ofPHC activities implementing this programme has increased tremendously. Annex 9 shows some of the QAP indicators used in PHC at the moment.
Besides the QAP, other quality initiatives are also now established in all PRC outlets, such as the Client Charter, Quality Control Circles, ISO 9000 certification, Work Culture Improvement etc. There is also the culture of innovation, and many award-winning innovative projects have been the products of PHC staff. Equipment and technology at PHC is another aspect that has undergone much quality improvement. Over time, some technologies deemed inappropriate before (especially for cost reasons) may now be appropriate. For instance almost all PHC outlets today are equipped with the ultrasonagraphy facilities, and some clinics are now equipped with the basic x-ray unit. There is continuous upgrading of the laboratory equipment and facilities. The number of drugs at PHC has expanded to include specialist items to cater for the specialists service now available, but within the limit of the National Essential Drug List to ensure appropriate choice and use, and to avoid unnecessary costs.
Human resource upgrading is another aspect that has improved quality ofPHC, such as the replacement of the midwife by the community nurse, the laboratory assistant by the laboratory teclmologist, and the introduction of the Family Medicine Specialist
5.9 Optimizing newer technologies
With the rapid advancement of both medical and information technologies, there is need for these to be used optimally. For PHC this is especially relevant because one of the principles ofPHC is the use of only appropriate technologies. In terms of medical technology, the PHC outlets in Malaysia have undergone several changes in diagnostics in the laboratory and in imaging service and pharmaceuticals (drugs and vaccines). Appropriate teclmology is ensured by many means, one is the requirement for technology assessment before a technology is applied. There is now a Health Technology Assessment Unit in the Ministry of Health. Appropriateness of technology has many facets, and one of them is cost-effectiveness. Health tec1mology assessment has now become a requirement including at PHC level, especially for those that have high costs. A recent
example is the technology assessment conducted for introducing the Haemophilus influenza B vaccine to the EPI.
In terms ofICT, Malaysia has taken very ambitious steps. The Telehealth Project has much to promise to overall health care including PHC. Specifically for PHC, the Ministry of Health is now putting in place the inputs for the Teleprimary Care (TPC) project. These benefits shall come through the various applications of ICT - teleconsultation, continuing medical education; mass customized and personalized health information and education, and the lifetime health plan. With this project, all PHC service points, shall be less isolated and have opportunities to be linked to other PHC outlets and other levels of care with greater ease and speed. This is in line with the policy of the Ministry of Health to use ICT not for its own sake, but using it as an "enabler" for making health care more accessible, more equitable and more efficient.
5.10 Harnessing other health systems - integrating TICM
As in all other countries the modem health system is not the only system that exists and are utilized by the people. There is a wealth of traditional and complementary and alternative health care systems that are not yet fully optimized. In Malaysia there is evidence that these traditional are used extensively. Thus the government has made it a clear policy that these be streamlined so that they are better regulated and can offer a viable and safe alternative for the community. In the effort to begin their integration, the Ministry of Health has formed a committee to see to the practice, the product, the training and the research aspects of T/CM. Currently work is being coordinated with five T/CM groups - these are three ethnic based practices (Malay, Chinese, Indian), homeopathy and complementary medicine.
16. THE CHALLENGESI
Many changes and challenges have occurred since the more than 23 years after Alma Ata. For simplification, these are looked at from four broad parameters. These are the user or consumer profile; the external environment such as the cbanging disease pattern; technologies in health and in communication and information (lCT); and the wider world including globalization and new world socio-economic-political realities.
6.1 The consumers of PHC
In the past the consumers ofPHC were mainly the rural and poorer Malaysians, whose purchasing power was very limited. Almost all of them were dependent on the free public services. Today they are more educated, wealthier and have a choice of accessing other providers of health care including the private sector. The education levels and increasing access to knowledge will change their perceptions of and expectations from the PHC system. Twenty years ago, they had less opportunities to information and modem communication technologies. Hence they had less demands and overall lower expectations of the PHC service. This has changed considerably, and there is now more and more rationale for PRC to not only meeting the "needs" of the consumers, but also their "wants and demands". This was measured by the level and distribution of responsiveness in the evaluation of health systems performance conducted by WHO for the 2000 World Health Report.
Malaysians today also have a longer life expectancy and are therefore more likely to have chronic degenerative diseases. Along with the socio-economic improvement, Malaysians today have a different lifestyle, which could be more detrimental to health, such as changing dietary habits and sedentary lifestyle. Some social and cultural norms are breaking down such as more women joining the workforce, the effect on infant and young child feeding practices, acceptance for women to smoke, more laxity in sexual behaviour, etc.
Another aspect of changing consumer profile is the issue of disadvantaged and marginalized groups. Despite great strides made in socio-economic development, there still remains pockets of disadvantaged communities such as the aborigines in the remote interior area, the estate workers and the poor (not only in rural but also in urban areas).
6.2 The external environment
In the early days ofPRC, basic environmental sanitation was a major issue since much of the rural population did not have access to safe water and sanitation. There were many infectious diseases especially food and water related diseases. Thus the Rural Environmental Sanitation Programme was, and still is, a major input to PRC. Food safety then was mainly a concem related to poor hygiene, but today the challenges are in chemical contaminants and other toxins. Urbanization then, had not extended to much of the rural populations. Today the picture has undergone great changes, and urbanization and industrialization has brought newer challenges, such as pollution of natural resources, and mental stress. The health needs of the urban poor is a great challenge. Malaysia is more fortunate than some the countries in the region in that there is much less natural disasters such as floods, earthquakes and volcanic eruptions.
Besides aging of the population, there are other demographic challenges in Malaysia such as rural-urban migration, a bigger population to be served and the phenomenon of in-migration (legal and illegal) from other countries, placing a stress on the health system especially PHe. As mentioned above, culturally and socially, Malaysia is undergoing changes. The status of women generally is not subservient, and they are not denied access to health care. However, when it comes to certain issues for decision making such as use of contraception and child spacing, there is still some male dominance. More families are becoming nuclear and ties are not as strong as they used to be, impacting on health care of children and the elderly.
6.3 Technological advances in health, and in leT
The PHe of 20 years ago used technologies which was then deemed "appropriate" for that time. The great advances made in medical technologies, in diagnostics, pharmaceuticals and others have made positive differences to PRC. However this is with an important caveat - their introduction is to be made with proper assessment. In Malaysia, almost all health clinics have seen a continuous improvement in their equipment. In terms of rCT, the gains made in PRe can be tremendous. The success for this however, has a lot to do with proper assessment and planning so that only those appropriate are introduced; and technology must not be used for its own sake, but rather to bring about benefits such as better equity. The inherent danger of advancement in lCT is the "digital divide" and the knowledge gap for disadvantaged communities, which will be against the basic principle of equity of PHC, and therefore has to be avoided.
6.4 Globalization and the new world order
The new paradigm in communications and globalization and related issues are a new threat to PRe. Because the world is becoming smaller, the exchange and movement of goods, people, lifestyle and culture has become easier, and this can have negative implications on PRe. World trade has become less regulated and the liberalization of free trade will make it easier for entry of low quality foods and drugs. Liberalization of policies may reduce the government's control over several determinants of health. If steps are not taken to protect the poor sector of the population, not only will poverty remain uneradicated, but further impoverishment may occur. An aspect of global mobility of people with serious health implications is the phenomenon of migration. Malaysia is dependent to some extent on foreign labour and there is a fairly large worker population. Because their recruitment and movement is regulated, such as the requirement of a pre-employment health screening, the possible negative impact health impact can be controlled to some extent. When it comes to the illegal migrants, which is a serious problem in some areas, the situation can be very difficult; and many of the related problems are at PRe level.
Ii. THE HEALTH IMPACTi
It is apparent that much has been achieved by PRC and the overall health system in Malaysia. As was mentioned earlier, these achievements are not solely the result of health intervention and PRC, because there is the significant influence of the wider secular factors on health status. These include overall socio-economic development, food availability, uplifting the status of women education, housing, transport etc.
In this review, "health impact" is taken to mean a few parameters of the outcome ofPRC, and these are described below in three parts (a) the utilization ofPRC by the population, (b) the impact in terms of their health status and (c) other related parameters such as efficiency and quality.
7.1 Acceptability and utilization (effectiveness) ojPHC
Before the health status as an impact is examined, it is pertinent to see first how well utilized the PRe services are. In Section 5, we have seen how the development of the PRe has led to more facilities being built and therefore suggesting increasingly better access. Having facilities available even if within a short distance does not always mean people will come to them to use them. The effectiveness ofPRC is measured by service access and utilization rates as exemplified by ante-natal care coverage, immunization coverage, school health coverage, oral and dental care etc. Indirectly, these rates measure the acceptability of the services, which is an important parameter and principle in PRC. There are also measures to indicate the activities at PHC level that are related to the essential services such as water supply and basic sanitation, disease prevention activities and food safety activities. Some of these indicators are shown in Annex 10.
7.2 Health status
The impact of the system can be measured by the health status of the population, measured by indicators such as life expectancy, disease or morbidity rates, and the mortality rates used intemationally especially matemal mortality, infant mortality and under-5 (toddler) mortality.
Morbidity or disease rates are dependent on a reliable disease notification or registration system. The incidences of the notifiable diseases (27 infectious diseases are notifiable under the law in Malaysia) in the past three decades are shown in Annex II. While most of these have declined, such as malaria, the vaccine preventable diseases and the food and water-bome diseases, the remaining challenges are the persistent infectious diseases that are still at relatively high incidence, especially dengue fever. Of the newly emerging infections, HN / AIDS remain a challenge. The Nipah viral fever outbreak of 1999 was a rude shock to the health situation of Malaysia. Besides these, the country is facing an increasing incidence of the chronic noninfectious diseases associated with aging, socio-economic betterment and a changing lifestyle. Annex 12 shows some of the relevant indicators for this new emerging health problem, presented as discharge and mortality rates in govemment hospitals due to diseases such as heart disease and cancer. These are the newer challenges for PHC.
This impact will result in desirable outcome, which is most easily measured by health status indicators such as population growth rate, life expectancy, crude birth and death rates, infant mortality rate, maternal mortality rate etc. These are shown in Annex 13, which also shows a few social determinants of health such as dependency ratio, literacy rate and educational attainment. Overall, Malaysia has made great progress in terms of these indicators. This marked improvement in the health status of Malaysians has, to some extent, been contributed by a PHC system that has ensured access and encouraged utilization.
7.3 Other measures of impact - efficiency and optimality (costs), quality
For the efficiency or cost-effectiveness, it is clear that PHC is very cost-effective. In the Malaysian context, the relatively little allocation to public health and primary health care has achieved comparatively much in health improvement. While this is not an easy parameter of success to measure, it is possible to use a proxy indicator, such as comparing the health budget to the impact indicators described above. Annex 14 shows a comparison among countries that show the health expenditure as a percentage of the country's GDP, and three indicators (life expectancy, infant mortality and population per doctor). It is seen that Malaysia has a relatively efficient service, with relatively low (3%) GDP for health but has achieved a reasonably good level of health. It is reasonable to assume that much of this is contributed by the health sector, especially PHC
The measures of quality are also evident such as the wider scope of services, the availability of more diagnostic tests including radiology and the expansion of the drug list at PHC levels. As was described in Section 5.8, there are various Quality Assurance Indicators that are used at PRC. Client satisfaction implies meeting not only of their needs but also of their expectations. In the QAP for primary care, one indicator is "client-friendly services". Another initiative to improve this is the Client Charter. In 1997, the Ministry of Health conducted an evaluation study on 17 quality initiatives, and overall, the results showed that quality of health care including PHC has improved after the introduction of these initiatives.
Is. COMMUNITY PARTICIPATION and DEVELOPMENTI
This principle of PHC has also been actively encouraged at all levels of management, but it is most apparent at community or primary level itself. There are various forms of this participation at local levels. In the state of Sabah and Sarawak where access is relatively more difficult, the community participation approach has been particularly successful. The following section describes the projects in these two states, followed by a mention of the community development projects that are also seen in the states of Peninsular Malaysia.
8.1 The Village Health Promoter (VHP) of Sarawak
The geographical terrain of Sarawak makes inaccessibility an inevitable feature. The Ministry of Health began outreach services many years ago in the form of mobile and traveling dispensaries, which today have taken the more comprehensive form of the Village Health Teams. Another scheme in Sarawak is the flying doctor service for the very remote areas. Still, there are certain disadvantages in these schemes. They are very costly and can only be provided at some intervals, which may not be frequent enough. They are also almost totally dependent on the health staff from the health department, with very little participation from the community. Most of the services, quite unavoidably, are curative in nature.
Community participation in Sarawak is not new. Indeed, as far back as the 1950's, there was already the "home help" scheme. Also, traditional healers including TBA's have always played a big role in the health of the various communities in the state. More recently, community participation took the form of building health facilities with the resources and efforts of the local community. But more meaningfully is the community participation by the Village Health Promoter (VHP) scheme, or Wakil Kesihatan Kampong (WKK) which started in 1973.
The members of the scheme, the village health promoters themselves, are from the community and selected by the community through consensus with the leadership of the official village elder. This elder in the longhouse of Sarawak is the "Tuai Rumah" or Headman. The promoters are trained in first aid, promotive and preventive activities, some curative activities and community development projects. The main thrust of the VHP is to improve health of their community by working in partnership with the health department. The health department provides support in the form of training and re-training, supervision, referrals, and in some instances, logistical support. The scheme is on a totally voluntary basis, although incentives are provided, such as recognition certificate, letter of recommendation when they apply for a paid job, study trips. Sometimes the community may give them a small token payment from their own collective resources.
The VHP has five objectives and these are:-
1. Ensure effective services are provided to remote areas where it is not cost-effective for
the government to build health facilities
2. Provide services that are responding to the real needs of the community
3. Provide services that are acceptable, available all the time and are cost-effective
4. Encourage mutually beneficial partnerships
5. In the long term, encourage the spirit of self-reliance in the community
When a community indicates that it needs a VHP, the health department studies the health characteristics of the community, which may be a village, a longhouse or a collection of a few
longhouses. Then the department consults the people of the community on these health situations and obtains their consensus on them. The community, with leadership from the headman, selects their VHP's, usually one man and one woman, who needs no qualification except being literate and motivated to serve his or her community. He or she must have a positive attitude and be acceptable to the community, The health department conducts a 3-week training course for new VRP's, and re-training is conducted every 5 years. They are given knowledge on a fairly wide scope of promotive, preventive and curative acre, and other health related matters.
A systematic evaluation of the VHP was conducted in mid 1980's and another evaluative study is now underway. There are clear benefits from this conununity development scheme, both for the health department and more importantly, for the community. There are currently about 1,600 VHP's in the state. Although attrition occurs, for various reasons (the commonest reason is a VP getting a regular paid job that gives him/her little time left for conununity work), new VHPs are continually recruited. The scheme is therefore viable and sustainable and effective in meeting its objectives. Truly, the VHP scheme in Sarawak is a project of the people, by the people, and for the people, which is in other words a form of "health democracy"
8.2 The PHC Volunteer of Saba" (for malaria control)
Malaria used to be a very serious problem in the state of Sabah. Although it is still a public health, it has become of a much lower magnitude. Community health work in malaria control began as early as 1961, but on an ad hoc basis. Following a study involving 3 interior districts and 15 volunteers in 1985, the Primary Health care Volunteers (PRCV) or Sukarelawan Penjagaan Kesihatan Asas (SPKA) scheme was fully implemented in the state in 1987. The PHCV is an adjunct to the anti-malarial measures and promotes active community participation, partnership, and responsibility, and in the longer term, a spirit of self-reliance.
The PHCV is a villager selected by the Village Development and Security Committee, and some of them are government employees elsewhere, e.g. school teachers. Many are fanners. Like the VRP of Sarawak, no qualification, except literacy and a positive attitude an motivation is required of the PRCV. There are currently, about 1,600 PHC in the state with an almost equal number of men and women volunteers.
One selected, the volunteers are given training by the local malaria team in the health office, on basic malariology, and the procedures and techniques that they will be carrying out as PHCV's. There is a standard manual for this training, which is conducted in 4 to 6 days at the district malaria office, with a one-day annual revision training.
The PRCV's do not work in isolation, and are under the supervision of the local malaria office. Their roles cover a wide range and include active and passive case detection, collecting blood and storing blood slides and sending these slides to the nearest laboratory. They also carry out presumptive treatment of suspected cases and radical treatment of confirmed cases; health education, assisting malaria health workers in spraying activities and bed net insecticide treatment. They are also taught on when and how to seek guidance and be aware of their limitations. For example they must refer all pregnant women and infants to the nearest health
This community health work is totally voluntary, but the PRCV is given some incentives, such as certificate of training and of appreciation, letter of recommendation such as when they apply for a job, identification tags and cards, and a sign board outside their house, field and study trips and free treatment at government hospitals. Their contribution is evident. In the year 2000, only
7.2% of malaria cases were detected by them. But this is no small contribution, these 415 cases would have remained undetected and be a source for other cases, because they were in very remote places not easily covered by the malaria workers in the health office. And they were detected at no cost to the office. Of all blood slides taken, the PRey's account to 10% which is more than 50,000 slides of the half million or so slides take each year.
While attrition is unavoidable and expected, the scheme has proved to be sustainable with newer recruits. What is encouraging, many of them are motivated by nothing else but the contribution that they are making to their own conununities.
As their name implies, the PRey does not necessarily limit his or her work to malaria control. In many districts in the state especially where malaria has become less of a problem, the PRey's are being trained to do a wider of activities. These include diagnosis of conunon simple ailments, giving simple safe treatment such as ORS for diarrhoea and anti-pyretics for fever, checking blood pressure and giving first aid. They also contribute to defaulter tracing and health education.
As in the VHP scheme in Sarawak, the PRey scheme of Sabah is of the people, for the people and by the people, - truly a "health democracy"
8.3 Other examples
While the two specific projects above have been particularly successful, there are other COI1U11Unity participation projects in the country, including in Peninsular Malaysia. Some of these are:
a) For each of the health clinic, there is an Advisory Panel with members from the community, and these panels have played important roles in case detection in case of treatment default, assisting people to access health facilities, distributing health pamphlets and in some cases carrying out health education.
b) A similar Board of Visitors are established for all hospitals and the members of these Boards are also active in activities for the conununity.
c) The PRe workers at the clinic are members of the bigger community group called the Village Development, Security and Health Committee.
d) There are many NOOs which are extremely active in health activities, and most of such NGOs are community based. There are therefore NGOs for cancer control work, breastfeeding promotion etc. There are many women NGOs which address and advocate for women's health from specific issues such as violence against women, family planning etc.
e) Several community-based rehabilitation (CBR) centers for rehabilitation of children with special needs are in place and the local conununities playa role in the development and running of these centers.
19. WHO AND OTHER INTERNATIONAL ORGANIZATIONSI
PHC in 1978 at the historical conference at Alma Ata had an intemational beginning, and WHO has since then taken a leading role in its implementation. The other international organizations related to health have also played significant roles in the success ofPHC in many countries including Malaysia.
The role of WHO can be seen from three inter-related perspectives:
(i) As an intemationalleading agency for health, and in this capacity, WHO is in a position to offer advice, policy guidelines and advocacy to governments. The credibility of the organization and its past successes make this role a very effective one.
For resource poor countries, WHO has been a very important source or provider of such required resources, including financial aid
The most frequently played role of WHO is of course as the coordinator and "broker" in health matters, and responsible for moving resources especially expertise among countries.
There are several effective mechanisms by which WHO plays these roles, such as the dissemination of information, procurement of consultancies and expertise, arranging study visits and the like, coordinating multi-centre research, and setting up the collaborating centres in some countries. Malaysia has been both a recipient of and a contributor to other countries through the coordination and "brokerage" of WHO.
The PHC in Malaysia has met with success in many specific areas, and Malaysia is therefore in a position to offer assistance by sharing its experiences with other countries. Indeed many countries have come to learn from these experiences. Some of the areas with relative strengths and successes are Ill:
Developing the PHC system itself
Safe motherhood and reducing maternal deaths
Childhood immunization - programme planning, implementation and evaluation Health systems research in the PHC setting
Quality improvements in health especially through the Quality Assurance Programme
Healthy City Projects (and other healthy settings as well) Health teclmology assessment
Developing standard operating procedures (SOP), and clinical practice guidelines (CPG) for PHC setting
Training of the Family Medicine Specialist
In addition, the various WHO Collaborating Centres in Malaysia have contributed and shall continue to contribute to the other member countries through the liaison of WHO. Specifically for PHC, the Collaborating Centre for Health Systems Research has vast potential for intercountry collaboration.
This as it may, Malaysia too is still in a position to require assistance in several areas ofPHC, and WHO is in the best position for procuring this assistance. Although the PRC in Malaysia has begun to expand the scope or content ofPHC (adolescent health care, community mental health, women's health, workers' health, elderly care, health care of children and people with special needs), these efforts are in relatively early stages, and much tec1mical assistance and guidance are needed.
Besides the WHO, the other international health related agencies also have significant roles in promoting and sustaining PRC in countries, especially the resource-poor countries. Malaysia has benefited tremendously from support from many such agencies, UNICEF, UNDP, UNFPA, the World Bank, the Asia Development Bank, to name a few.
Annual Report of the Department of Public Health, Ministry of Health, 1999
IDS, Ministry of Health Malaysia; Health For All Indicators 1999
Abu Bakar S, Jegathesan M et al ; Health in Malaysia - Achievements and Challenges
Mohammad Taha A; The Health System of the Future (unpublished)
Mohammad Taha A, Gracia T, Sarjit S et al; Evaluation of the Village Health promoter of Sarawak (1987), unpublished
Maimunah H, Narimah A, Safurah J; The Structure and Sustainable Delivery of Essential Public Health Functions in the Western Pacific Region, July 2001 (unpublished)
Narimah A; From Alma Ata to the New Millennium - The Changing face of Quality in Primary Health Care, Sept 2000 (unpublished)
Narimah A; Primary Health Care - Past, Present and Future, Nov 2000 (unpublished)
Maimunah H, Sondi S, et al; Recent Illnessiinjury and Health Seeking Behaviour, Volume 3 of the report of the Second National Health and Morbidity Survey, Ministry of Health Malaysia (1996)
10. Sarawak Health Department; The Village Health Promoter Working Guide for Trainers and Supersivors
11. Ho KB; Primary Health Care Volunteer in the Control of Malaria in Sabah (unpublished)
I would like to acknowledge and thank the following people for having assisted me in the conduct of this review, and the preparation of this report.
1. The Director General of Health, Datu Dr.Mohammad Taha Arif, for his overall advice and guidance, and for his ideas in the paper "Health System a/the Future" which I had the privilege of using as reference for this review
2. The Deputy Director General of Health (Public Health) Data' Dr Tee Ah Sian for her advice and her understanding in allowing me time away from other routine duties to conduct this review
3. The State Director of Health of Sarawak, the State Family Health Officers, the Divisional Health Officer of Miri and all their staff; along with the Village Health team from Marudi and the Village Health Promoters of the Kejaaman and Terajau Longhouses in Baram; for helping me to see first hand and learn from the exemplary community participation in Primary Health Care in Sarawak
4. The State Director of Health of Sabah, the State Family Health Officers, the State Officers for Control of Vector-Borne Diseases, the Keningau and Tuaran Medical Officers of Health, and their staff; and of course the PRC Volunteers themselves; for giving me invaluable insights into the role of community participation in PHC for malaria control in Sabah.
5. Officers and staff in my own office, the Division of Family Health Development for their help, motivation and understanding
14 . .........
( \ ~J
Policy statements related to Primary Health Care in Malaysia
Objectives of the Ministry of Health for the 8th Malaysia Plan (2001-2005)
Organization ofPHC in the Ministry of Health Malaysia
The two-tier PHC System in Malaysia
PHC facilities and their distribution, as of 31 Dec 1999
Selected categories of human health resource, 1999
The budget of the Ministry of Health 1999
Health and health related indicators for monitoring and evaluation of "Health For All"
Selected Quality Assurance Programme (QAP) indicators at PHC
Utilization (coverage) rates of selected PHC services, 1995 and 1999
Incidence of selected notifiable communicable diseases, 1979, 1989 and 1999
Discharge rates and mortality rates in government hospitals of selected noncommunicable diseases, 1990 and 1999
Selected health status indicators, 1990 and 1999
Health expenditure as a percentage ofGDP and health status in selected countries 1990
ANNEX 1: POLICY STATEMENTS RELEVANT TO PRIMARY HEALTH CARE IN MALAYSIA
By the year 2020, Malaysia is to be a united nation, with a confident Malaysian Society, infused by strong moral and ethical values, living in a society that is democratic, liberal, and tolerant, caring, economically just and equitable, progressive and prosperous, and in full possession of an economy that is competitive, dynamic, robust and resilient.
VISION FOR HEALTH
Malaysia is to be a nation of healthy individuals, families and communities, through a health system that is equitable, affordable, efficient, technologically appropriate, environmentally adaptable and consumer-friendly, with emphasis on quality, innovation, health promotion and respect for human dignity, and which promotes individual responsibility and community participation towards and enhanced quality of life.
MISSION OF MINISTRY OF HEALTH
The mission of the Ministry of Health is to build partnerships for health to facilitate and support the people to:
• Attain fully their potential in health
Motivate them to appreciate health as a valuable asset
• Take positive action to improve further and sustain their health status to enjoy a better quality of like
THE EIGHT HEALTH SERVICE GOALS OF THE MINISTRY OF HEALTH
1. From illness to well ness
2. From provider to client (person) focus
3. Providing service to the informed person
4. Encouraging self-help and self-care
5. Care near to home
6. Care customized to client's needs
7. Continuous and seamless care
8. Efficient and affordable health care of quality
ANNEX 2 : OBJECTIVES OF THE MINISTRY OF HEALTH FOR THE 8 TH MALAYSIA PLAN (2001 - 2005)
The following are some of the objectives of MOH for the 8MP (2001 - 2005)
To ensure priority consideration of equity of access to health services in terms of geographical, cost, comprehensiveness and continuity of care.
To ensure attainment of quality care through availability of trained personnel, appropriate technology, optimal resources and acceptable standards of practice.
To motivate people to value their health and be committed to actions to maintain and improve their health status.
To strengthen the Primary Health Care approach in delivery of health care through health promotion, prevention, curative and rehabilitative services.
To provide high quality and comprehensive medical care services, with a continuum of care from acute to rehabilitative, using appropriate technologies to improve health outcomes.
To strengthen inter-agency and intra-agency coordination, cooperation and sharing of resources including information, etc
ANNEX 3: ORGANISATION OF PHC IN THE MINISTRY OF HEALTH MALAYSIA
MINISTRY OF HEALTH
1 1 1 1 1
, .L ,
STATE HEALTH DEPT.
1 1 1 1
1 1 I 1
DISTRICT HEALTH OFFICE
PHC LEVEL providing the package of essential services (serving
about 20,000 pop.) and having full complement of PHC manpower
Limited service (mainly MCH and outpatient care for minor ailments) (serving between 2,000 to 4,000 pop.)
THE TWO-TIER PRIMARY HEALTH CARE SYSTEM IN MALAYSIA
COMMUNITY (**) CLINIC (2,000 - 4,000)
COMMUNITY CLINIC (2,000 - 4,000)
HEALTH (*) CLINIC (15,000 - 20,000 population)
COMMUNITY CLINIC (2,000 - 4,000)
COMMUNITY CLINIC (2,000 - 4,000)
The Health Clinic provides all the 8 essential services, plus dental care, and has expanded the scope further to include elderly health, adolescent health, mental health, etc.
(**) The Community Clinic (Klinik Oesa) provides maternal and child health service, and outpatient treatment of minor ailments
Note: In the previous THREE-TIER system for PHC, there were the Main Health Centre, the Health Sub-centre, and the Midwife's Clinic-cum-Quarters.
ANNEX 5: PHC FACILITIES AND THEIR DISTRIBUTION, MALAYSIA AS OF 31 DECEMBER 2000
DISTRICT HEALTH COMMUNITY MCH MOBILE
STATE POPULATION HEALTH
OFFICE CLINICS CLINICS CLINICS CLINICS
Perl is 224,900 1 9 30 1 0
Kedah 1,646,100 11 54 225 9 8
Penang 1,299,400 5 29 62 6 0
Perak 2,311,800 9 82 252 7 19
Selangor 2,981,700 9 58 135 12 4
K.Lumpur(*) 1,466,500 0 14 0 0 0
N.Sembilan 852,300 6 39 103 5 2
Melaka 633,700 3 27 63 1 1
Johor 2,617,100 8 87 271 7 5
Pahang 1,302,600 11 65 235 8 23
Terengganu 997,900 7 41 133 2 1
Kelantan 1,512,000 10 58 199 2 11
Sabah 2,292,700 11 91 190 19 8
Sarawak 2,074,100 15 189 26 25 122
Total 106 843 1,924 104 204 ANNEX 6 : SELECTED CATEGORIES OF HEALTH HUMAN RESOURCES IN MALAYSIA 1999
PUBLIC 'PRIVATE TOTAL
.. - ~- :_: ;: (:: . ~ - .~.
Number 8,723 6,780 15,503
Population Ratio 1 : 2,604 1 : 3,350 1 : 1,465
Number 803 1,106 1,909
Population Ratio 1 : 28,284 1 : 20,535 1 : 11,897
Number 401 1,917 2,318
Population Ratio 1 : 56,638 1 : 11,848 1 : 9.798
Number 20,914 6,322 27,236
Population Ratio 1 : 1,086 1 : 3,593 1 : 834
Number 6,731 180 6,911
Population Ratio 1 : 3,374 1:126,177 1 : 3,286 u
ANNEX 7: BUDGET OF MINISTRY OF HEALTH, 1999
Total MOH Budget = RM 4,237,960,000 Operating = RM 3,494,774,000 Development = RM 743,186,000
Per capita allocation RM 191.00
% of MOH budget to National budget = 6.61 %
Total budget for Public Health Programme = RM 653,605,260 Which is allocated to the activities as follows;-
PUBLIC HEALTH For Existing policies For new policies
Family Health & Primary RM 395,453,192 RM 4,976,100
Disease Prev & Control RM 137,326.963 RM12,900,000
Dental and oral health RM119,450,973 RM 5.300,000
Food Quality Control RM 11,481,557 RM 1,540,000
Health Ed ucation RM 8,978,113 RM 2,600,000
Admin RM 64,575,702 NIL
Total RM653,605,260 RM27,316,100 Note: (1) All the above activities have direct inputs into the Package of essential services provided at PHC level.
(2) The above does not include budget for water and
Sanitation activities which amount to about lUv120 million
ANNEX 8: CATEGORIES OF HEALTH AND HEALTH RELATED INDICATORS FOR MONITORING AND EVALUTING "HEALTH FOR ALL"
The following 4 categories of indicators are being monitored by the Ministry of Health since the first Common Framework of Monitoring (CFM) was carried out in 1982, and the Common Framework of Evaluation (CFE) in 1985, by WHO
Social and socio-economic indicators school enrolment by gender
per capita CNP
annual population growth total dependency ratio urban and rural population literacy rate
% distribution of low birth weight
2. Health status indicators
perinatal, neonatal, post-neonatal and infant mortality
deaths and specific age groups livebirths and crude birth rate deaths and crude death rates industrial absenteeism
Specific health problem indicators
incidence rate and mortality rate of communicable disease
discharge rate and mortality rate of specific non-commicable disease (CVO, cancer, malnutrition, specific metabolic disease)
incidence rate of motor vehicle accidents and industrial accident
oral health indicators (% of schoolchildren who are dentally fit, dental caries rate)
4. Health Services Improvement Indicators
The are many indicators, and among them are:distribution of facilities and other resources service coverage rate such as immunization, antenatal care, etc.
school supplementary feeding safe water and sanitation
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ANNEX 10: UTILIZATION (COVERAGE) OF SELECTED PHC SERVICES, 1995 AND 1999
Antenatal attendance 68.8 69.6
(govt. facilities only)
Tetanus Toxoid coverage for pregnant mothers 80.2 85.6
- BCG 99.5 100.1
- DPT (3) 89.9 93.2
- OPV (3) 89.9 93.2
- Hepatitis B (3) 87.1 90.7
- Measles 82.2 86.6
School Health (Primary I)
- Examined by nurse 97.1 97.9
- Examined by doctor 64.4 50.8
- Booster (OPT and OPV) 95.5 96.0
Oral Health and Dental Services
- Preschool 26.8 (*) 32.9
- Primary School 98.4 (*) 99.5
- Secondary School 59.4 (*) 71.2
- Antenatal Mothers 14.2 (*) 15.6 (*) ~ 1997 figures
Other utilization measures (1999)
Outpatient care at Primary Health Care ~ 15,463,554 cases (54.6% of all outpatients)
Population served with safe water: Rural ~ 86% Urban ~ 97%
Population served with sanitary latrines: Rural ~ 99% Urban ~ 100%
ANNEX 11: INCIDENCE OF SELECTED NOTIFIABLE COMMUNICABLE DISEASES, MALAYSIA 1979, 1989, 1999
1979 1989 1999
Food and water borne
cholera 501 (10) 393 (14) 536 (9)
Typhoid 1,920 (26) 1,785 (3) 811 (2)
Dysentry 980 (1) 633 429
Food poisoning 826 (2) 1,782 (2) 8,640 (3)
I:'· ...... niL .: . ....
........ >:.: ;..,::
Diptheria 98 (10) 35 (6) 6 (1)
Tetanus 53 (6) 21 (4) 10(2)
Pertussis 105 25 17
Poliomyelitis 4 0 0
Tuberculosis 11,218 * 10,686 (781) 14,908 (119)
Measles 6,352 (4) 1,027 (2) 2,603 (10)**
483 (in 1998)
I> .. · .. :. ....> \;;mr ·•·••·.· .: :··.:· .•• ·· •. ·<:::·· •• ::·::.·, •• · •.•• ':,.',Ui 1::';'·;.·:: •• • •••• .: : . ...
:. : .. :
Vector borne diseases:
Malaria NA 69,127 (62) 11,106 (21)
Dengue Fever 372 * 2,047 9,602 (6)
D. Haem Fever 300 (25)* 517 (16) 544 (31)
.... .: •••• : r : , •••• .:: ... 1;,'< ....•.•........ ' .
HIV (infection) 0 202 (1) 4,692 (874)
Syphilis 590 1,969 2,150
Gonococcal 2,676 5,459 2,232
... if> H·i ': .... :'.:::.,' I/:<··Y>'C ;.:.; ' ...... , : ..
Leprosy 334 329 224 * - 1980 data ( ) - deaths
** - There was measle outbreak in 1999
ANNEX 12: DISCHARGE RATE AND MORTALITY RATE IN GOVERNMENT HOSPITALS (PER 100,000 POPULATION) OF SELECTED NON-COMMUNICABLE DISEASES, 1990 AND 1999
DIS'EASE 1990 1999
Discharge (mortality) Discharge (Mortality)
1. Ischemic Heart 124.8 (12.0) 133.1 (9.2)
2. Heart Failure 37.9 (4.7) 37.2 (3.9)
3. Hypertension with 17.4 (0.3) 9.2 (0.1)
4. Cancer of Trachea, 18.0 (2.7) 17.3 (2.5)
Bronchus and Lungs
5. Cancer of Cervix and 13.3 (0.5) 11.4 (0.4)
6. Cancer of Female 13.7 (0.8) 17.9 (0.8)
7. Cancer of Stomach 7.9 (0.8) 5.4 (0.7) ANNEX 13: SELECTED HEALTH STATUS INDICATORS MALAYSIA, 1990 AND 1999
Total Population 17,763,900 22,179,500
Annual Growth Rate 2.5% 2.3%
Life expectancy (at birth)
Male 68.8 years 69.6 years
Female 73.4 years 74.9 years
Crude Birth Rate 28.4 per 1,000 24.4. per 1,000
Crude Death Rate 4.7 per 1,000 4.6 per 1,000
Mortality Rate (per 1,000 live births)
Perinatal Mortality Rate 13.4 7.9
Neonatal Mortality 8.5 5.2
Infant Mortality 13.1 8.5
Toddler Mortality 1.0 0.7
Maternal Mortality 0.2 0.3
Low Birth weight Babies 9.0 8.2 The health status of the population is largely contributed by the determinants of health outside the health sector. Some of these are:
1. Literacy rate: Urban ~ 90%, Rural ~ 80%
2. Educational attainment: Primary School ~ 39%
Secondary School ~ 38%
Tertiary ~ 7%
Never Attended ~ 16%
Dependency ratio ~ 59.6%
ANNEX 14: HEALTH EXPENDITURE AS A PERCENTAGE OF GDP AND HEALTH STATUS IN SELECTED COUNTRIES) 1990 (indicator of Efficiency and Cost-Effectiveness)
Country Health Expend Life Expectancy Infant Mortality Population
(% of GOP) (Years) Rate (1991) Per doctor
Korea 6.6 72 16 1,370
Hong Kong 5.7 78 7 820
Thailand 5.0 68 27 5,000
Papua New 4.4 52 55 12,870
Sri Lanka 3.7 72 18 NA
China 3.5 69 38 1,060
MALAYSIA 3.0 71 15 2,700
Philippines 2.0 64 41 8,120
Indonesia 2.0 59 74 7,030
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