Professor, Health Innovation, Curtin Health Innovation Research Institute, Curtin University, Perth, Australia
Sajaratulnisah Othman MBBS MMed (Fam Med) PhD
Primary Care Consultant
Nik Sherina Hanafi MBBS MMed (Fam Med) PhD
Chirk Jenn Ng MBBS MMed (Fam Med) PhD
Ee Ming Khoo MBBS MRCGP MD
Yook Chin Chia MBBS FRCP
Department of Primary Care Medicine, University of Malaya, Kuala Lumpur, Malaysia
Malaysia has achieved reasonable health outcomes even though the country spends a modest amount of Gross Domestic Product on healthcare. However, the country is now experiencing a rising incidence of both infectious diseases and chronic lifestyle conditions that reflect growing wealth in a vibrant and successful economy. With an eye on an ageing population, reform of the health sector is a government priority. As in other many parts of the world, general practitioners are the first healthcare professional consulted by patients. The Malaysian health system is served by public and private care providers. The integration of the two sectors is a key target for reform. However, the future health of the nation will depend on leadership in the primary care sector. This leadership will need to be informed by research to integrate care providers, empower patients, bridge cultural gaps and ensure equitable access to scarce health resources.
chronic disease, healthcare, Malaysia, primary care
It is imperative that the increasing magnitude of chronic disease burden is anticipated, understood and acted upon urgently. Chronic disease prevention and control can no longer be ignored as an important means of economic development.
The proportion of the world’s population that cur-rently lives in China and India has been estimated to be 36.5%.[2,3] By also factoring in the populations of Indonesia, Pakistan and Bangladesh, one may con-clude that the majority of the world’s people live in Asia. Therefore, health innovations that could improve health in Asia would serve most of the world’s people. For example, according to the World Health Organization, South East Asia has the highest number of new cases of tuberculosis and measles in the world; it also has the highest incidence of congestive heart failure due to rheumatic heart disease, hypertensive heart disease, ischaemic heart disease or inflammatory heart disease. This paper explores the scope to design solutions to Asian healthcare challenges using Malaysia as an exemplar.
Malaysia is the southern gateway to Asia, its territory straddling the Asian mainland and the Malay archi-pelago. There are two distinct parts to the country, east (Peninsular) Malaysia and the west. Malaysia shares land borders with Thailand, Indonesia and Brunei, and maritime borders with Singapore, Vietnam and the Philippines. In 2010, the population exceeded 27.5 million. The Malaysia of today is a highly successful market economy. It is weathering the global financial crisis better than many countries in Europe. Per capita gross domestic product (GDP) makes it the third largest economy in the Asscoiation of Southeast Asian Nations (ASEAN) and the 29th largest in the world. In 2008, the infant mortality rate, a standard in deter-mining the overall efficiency of healthcare, was 6.4 per 1000 live births, comparing favourably with the USA and Western Europe. Similarly, in 2008, life expect-ancy at birth was 71.6 years for men and 76.4 years for women.[7,8] Rapid and sustained increases in material wealth have been reflected in the growing incidence of conditions normally managed almost exclusively in primary care, including many ‘lifestyle-related’ con-ditions more usually seen in Europe, Australia and North America. For example, the prevalence of diabetes mellitus is quoted as being 14.9% of the Malaysian adult population in 2006, nearly double the prevalence reported a decade previously. This reflects increasing obesity, but also the genetic susceptibility of a South East Asian population.
As gatekeepers to the healthcare system, Malaysian primary care practitioners see patients at a point when prevention and effective treatment are still possible. In this regard, the frequently quoted ‘ecology of medical care’ has resonance for primary care practitioners in Malaysia. Not only are doctors in primary care the first to see people when they need medical advice, but they also provide continuity of care and holistic management for those who develop chronic and life-limiting illness. Arguably the most important part of the health service, primary care is provided by both the public and private sectors. In 2009, there were 5104 private primary care clinics and 806 publicly funded health clinics. The overall density of primary care clinics was 2.09 per 10 000 population. The number of private clinics outnumbered public clinics by 6.3 to 1, whereas the overall primary care practitioner to population ratio was 2.89 per 10 000 population.
Malaysia as an exemplar of healthcare in Asia
Malaysians enjoy excellent health, although at the same time the country spends a modest 4.75% of GDP on health services. There are compelling reasons why health innovators and policy makers worldwide may gain from studying the Malaysian experience, especially in primary care. Primary healthcare has been at the forefront of health services in Malaysia since 1996. The government-funded primary health-care sector is the main service provider, as reflected by the fact that primary healthcare expenditure con-stituted 58.4% of the total national healthcare budget in 2006. The government is now proposing a reform of the healthcare finance system. As in neighbouring Australia, there is a growing recognition of inequity, with some people experiencing far worse health out-comes than others. While most Malaysians enjoy excellent access to healthcare, a significant proportion, particularly those with modest means, residents in the east of the country and aboriginal Malaysians, have limited access. The have-nots may find themselves treated in overcrowded, understaffed clinics and ultimately in hospitals comparable with the poorer parts of Asia and Africa. Most services at public health clinics are provided by assistant medical officers and nurse practitioners. The role of nurse practitioners in providing primary care is a growing feature in Malaysia and is in urgent need of evaluation. There may also be a separation of prescribing and dispensing services from the existing dispensing services by the primary care clinics. The financial impact on the private sector has yet to be established as the income of most private clinics through loss of dispensing will be threatened. The impact of these financial changes on healthcare provision has yet to be defined.
Epidemiology in Malaysia features a double disease burden – conditions that are found in developing countries including – infectious diseases (HIV, tu-berculosis and dengue) are emerging or re-emerg-ing.[16,17] Malnutrition and poverty are matched by the impact of material wealth, including a rising incidence of diabetes, cardiovascular disease, cancer and mental illness.[18,19] Malaysia has a population that is both ethnically diverse and ageing. The incidence of con-ditions related to ageing, including falls and dementia is set to rise steeply. How can Malaysians be supported to care for a dependent ageing population within the context of a multicultural population? It is envisaged that the main burden of healthcare for the elderly will be within primary care. Malaysia is also a multi-ethnic and multicultural country. This provides a crucible to explore transcultural issues in healthcare and to study the interaction between environmental and genetic factors on health. Moreover, with a focus on traditional and complementary medicine, Malaysian researchers may be able to define how these treatment choices might influence help-seeking behaviour and health outcomes in other parts of Asia.
What can we learn from the Malaysian experience?
There are a number of areas where the experience in Malaysia may predict future health on the Asian mainland. How will healthcare reform in Malaysia impact on health outcomes? Some have questioned the need to reform a system that is already serving the population well. Others have pointed out that there is evidence that Malaysians experience poor outcomes in diabetes and heart disease, similar to neighbouring Australia, and that the demographic changes on the horizon warrant a proactive approach to reform. These changes are also on the horizon for other parts of Asia.
The current system where healthcare is highly subsidised in government-funded health clinics means that many people with chronic and complex con-ditions are seeking help in the public sector, while those with acute and self-limiting minor illness are more likely to present to private medical practi-tioners.[22,23] It remains to be seen if the trend of utilising publically funded clinics for the more ex-pensive healthcare conditions can be sustained with the predicted rise in lifestyle-related chronic illness in an economically thriving nation. If the public system needs to be reformed, how will this impact on the affordability of healthcare and how will this be reflected in the prognosis of chronic conditions? The proposed healthcare reforms aim to integrate the public and private sectors. Will this lead to a more cost-effective system with improved quality and equity of care? Which payment mechanism should be used for effec-tive and affordable healthcare? Should national in-surance with minimal co-payment be introduced?
Can the quality of care of publically funded clinics ensure the best outcomes for patients? As the focus moves from treatment to prevention and patient empowerment, is the system fit for purpose? The demand for access to services is predicted to rise, but similarly, changes in the dynamics of the relationship between doctor and patient are reflected in the trends for greater litigation and complaint. How will the increasing pace of change in Malaysian society, with a focus on information technology, be reflected in the redesign of effective primary care services? For example, what will be the impact of telehealth? In add-ition, there are now 35 medical schools in Malaysia. The increase in numbers was an attempt to improve the patient-to-doctor ratio with the aim of achieving the healthcare status of a developed country. As most graduates enter primary care, more may be consider-ing a career abroad as the market becomes saturated. To what extent will this rise in medical manpower be reflected in improvements to health outcomes for Malaysians? Will this reduce the discrepancy in medi-cal manpower between rural and urban areas as well as east and west Malaysia?
The Malaysian government is committed to refur-bishing existing hospitals, building new hospitals, expanding the number of polyclinics, improving training and expanding telehealth. However, given the pivotal role of primary care and without invest-ment in research in that sector, the question of how the healthcare system can best respond to the needs of a country facing increasingly rapid growth and econ-omic development has not been answered. The key questions that primary care research must help to answer include the following:
How can patients with chronic disease be served within a population that has such marked ethnic, cultural and social differences: where poverty exists alongside fabulous wealth, where acute infectious illness is still a significant healthcare issue and where there is still systemic inequity of access to health-care?
How will primary care accommodate the need for healthcare reform? Can the commitment to conti-nuity of care and the gatekeeper role of the general practitioner be sustained and lead to a more effec-tive and efficient health system?
•How can the population be more engaged in healthcare decisions and will patient empower-ment be promoted as a major issue in healthcare as in the West?
•Is there an adequate understanding of cultural sensitivities and needs when managing health-related issues in the population? Cross-cultural research will help to unveil issues pertaining to communi-cation, health beliefs and help-seeking behaviour, which may be applicable to the rest of the world as globalisation occurs.
•Will public–private integration lead to a more efficient healthcare system?
•Will the quality of care be affected by allowing other than doctors to prescribe?
Malaysia is at the crossroads between the developing and the developed world; facing east and west; es-pousing new and old health systems; and confronting new, lifestyle-related chronic conditions as well as infectious diseases that are more prevalent in devel-oping countries. There is a growing need to conduct health system research with outcomes that may guide other countries, especially in Asia, where most of the world’s people live.
Commissioned; not externally peer reviewed.
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