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MANAGING CHRONIC DISEASES IN THE MALAYSIAN PRIMARY HEALTH CARE – A NEED FOR CHANGE

AS Ramli MBBS (Newcastle-upon-Tyne), DFFP (UK), DRCOG (UK), MRCGP (UK), Senior Lecturer & Family Medicine Specialist, Faculty of Medicine, Universiti Teknologi MARA (UiTM), Shah Alam, Selangor, Malaysia

SW Taher, BSc.Med.Sc (St. Andrews), MBChB (Glasgow), M.Med (Fam. Med UKM), Family Medicine Specialist & Fellow in Primary Care Chronic Disease Management, Klinik Kesihatan Simpang Kuala, Alor Setar, Kedah, Malaysia

Address for correspondence:
Dr Anis Safura Ramli, Senior Lecturer & Family Medicine Specialist, Primary Care Medicine Discipline Coordinator, Faculty of Medicine, Universiti Teknologi MARA, 40450 Shah Alam, Selangor, Malaysia. Email: rossanis_yuzadi@yahoo.co.uk

INTRODUCTION

The disease profile of the world is changing at an alarming rate. Chronic diseases include heart disease, stroke, cancers, chronic respiratory diseases, diabetes and mental disorders are now accounted for 47% of the global burden of disease and 60% of all deaths.¹ World Health Organisation (WHO) in its groundbreaking report Preventing Chronic Diseases: a Vital Investment shows that 80% percent of chronic disease deaths occurred in the low and middle income countries and 50% of these deaths occurred prematurely in people under 70 years of age, disputing the long-held notions that chronic diseases are mainly affecting affluent countries and older generations.² In Malaysia, WHO estimated that chronic diseases accounted for 71% of all deaths in 2002, using calculation based on the standard methods to maximise cross-country comparability.³ The first Malaysian Burden of Disease and Injury Study showed that the top two leading causes of deaths in the year 2000 for both sexes were ischaemic heart disease and cerebrovascular disease; and the total years of life lost for the Malaysian population in 2001 was 1.7 million years with almost two-thirds of this burden of premature deaths resulted from chronic diseases.⁴ Of the total burden of disease measured using Disability Adjusted Life Years (DALYs), approximately 69% was contributed by chronic diseases.⁴

Globalisation, urbanisation, population ageing, as well as general policy environment has been identified as the underlying determinants responsible for the changing pattern of diseases in developing countries.² Malaysia is of no exception in terms of the effect of urbanisation, as an estimated 63% Malaysians now live in urban areas.⁵ Although only 6.6% of Malaysians are aged 60 years and above, the ageing population is projected to gradually rise as the life expectancy at birth for both males and females has increased over the years to 70.6 years for males and 76.4 for females in 2005.⁵  Preliminary data from Malaysian Non-Communicable Disease (NCD) Surveillance 2005/06 estimated that approximately 11.6 million Malaysian adults aged 25-64 years were having at least one risk factor for chronic diseases and only about 3% did not have any risk factor. ⁶ A recent national survey which sampled more than 16,000 Malaysians, showed that the prevalence of hypertension amongst those aged 30 years and above has increased from 32.9% in 1996 to 40.5% in 2004,⁷ while the overall prevalence of obesity amongst those aged 15 years and above was 11.7% in 2006, which is a staggering increase by 280% since the last National Health and Morbidity Survey II (NHMS II) in 1996.⁸

Given the dramatic upsurge of chronic diseases and their risk factors, this paper aims to describe the current situation of how chronic diseases are managed in the Malaysian primary health care to highlight the need for change, discuss some of the barriers to the implementation of effective chronic disease management programmes in the community, and consider fundamental solutions needed to instigate the change in our setting.

CHRONIC DISEASE MANAGEMENT IN THE MALAYSIAN PRIMARY HEALTH CARE SYSTEM: CURRENT SITUATION

The defining features of primary care practice – that is, continuity, comprehensiveness and coordination⁹ – can potentially be the cornerstone of high quality medical care much needed by patients with chronic conditions. Evidence has shown that if effective primary care and coordination are lacking, patients with chronic conditions are at increased risk of hospitalisation, adverse drug reactions and complications.^10,11 While population-wide approach forms the central strategy for preventing chronic disease epidemics, it remains pertinent that this should be combined with comprehensive, integrated and coordinated care at the primary care level, focusing on those at high risk and those with established diseases.2  The World Bank Report 2007: Public Policy and the Challenge of Chronic Noncommunicable Diseases shows that prevention and control of chronic diseases by public health policies and primary care interventions were more cost-effective when compared to secondary and tertiary care interventions.¹²

Malaysia has a multiethnic population of 26 million and is classified as an upper middle income country by the World Bank in 2003, based on its Gross National Income (GNI) per capita. It spends 4.3% of its Gross Domestic Product (GDP) towards health in 2006.¹³ Primary health care has been declared as the thrust of health services since the documentation of 7th Malaysia Plan in 1996 and it is presently provided by both the public and private sectors.¹⁴ The public primary health care sector is the main service provider where the total primary health care expenditure was 58.4% of the total health care expenditure in 2006.¹³ Significant progress has also been made in terms of infrastructure where there are 809 Health Clinics, 1919 Community Health Clinics, 95 Maternal and Child Health Clinics, and 168 Mobile Clinics sprawled all over the country.¹⁵ Services are highly subsidised at minimal or no cost to the patients and are delivered by team members consisting of doctors, paramedics, nurses and other support staff. A large proportion of public primary health care facilities are not equipped with electronic clinical information system but significant progress is now being made since the Teleprimary Care (TPC) project has been piloted in 4 different states in Malaysia.¹⁶ The second major provider of primary health care services is the private sector where there are approximately 8,000 private general practitioners and private primary care clinics have been mushrooming throughout the country, especially in urban areas, to a total of 7454 in 2004.¹⁵ These clinics are largely run by either single-handed or a group of 2-3 general practitioners, often without the complement of allied health care staff. Out of the 7454 private primary care clinics, approximately 800 are currently equipped with various discrete electronic medical record systems which are not designed to communicate with one another.¹⁷ Payment for the services provided are largely borne by the patients or their employers.

In Malaysia, most people with chronic diseases are already receiving their care at the primary care level. Data from the TPC project for predicting utilisation of health services showed that a larger proportion of patients with chronic medical conditions received their care at the public primary care clinics as compared to private clinics (the data from the private clinics may not be representative due to the small number).¹⁶ Better quality data is needed to make a valid comparison between the public and private primary care sectors with regards to the morbidity patterns, resource utilisation and practice patterns. In terms of quality of care for chronic conditions, results from numerous primary care based studies and audits have consistently showed that substantial proportions of these patients have not received effective therapy and do not achieve optimal disease control.^{7, 18-22} A recent national study on hypertension showed that only 34.6% were aware of their hypertensive status; and of the 32.4% who were taking antihypertensive medication, only 26.8% had their blood pressure under control.⁷ A diabetes study in private primary healthcare in Malaysia showed that only 12% of the patients had their HbA1c measured in the preceding 12 months and >80% were not satisfactorily controlled; and this was associated with high prevalence of complications.²⁰ A cross-sectional study of lipid profiles of patients with diabetes mellitus at a public primary health care centre showed that dyslipidaemia was still under-treated and of those receiving treatment, only 22% achieved the treatment target for LDL-C level. ²²

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