REVIEW ARTICLE
MANAGING CHRONIC DISEASES IN THE MALAYSIAN PRIMARY HEALTH CARE – A NEED FOR CHANGE
Sporadic efforts are being made in the public primary care sector to manage chronic diseases such as diabetes and hypertension in a more systematic way using care teams while most of the other problems including chronic respiratory conditions are still being managed in ‘walk-in’ general clinics. Widespread implementation of multidisciplinary team approach for chronic diseases is often hampered by acute shortage of trained personnel. Currently, there are only 160 Family Medicine Specialists (FMS) covering 12% of the public primary health care clinics throughout the country.This situation is made worse when only 1097 of 2126 Medical and Health Officers (M&HO) posts are filled, and 129 nutritionists recruited out of 191 available posts. Drug availability is still limited, especially the newer and more expensive agents. National disease registry projects e.g. for hypertension (Hi-Trax) and diabetes (DiMer), are at different stages of being piloted, but the progress is very slow as most of the public primary health care clinics lack information technology (IT) capacity. In the private sector, even though most clinics offer care for chronic conditions such as hypertension, diabetes and asthma, they are generally underused by patients due to the high cost of long-term treatment and absence of organised funding mechanism. These clinics are mainly equipped to react to acute illnesses with the majority of the workload revolves around diagnosing and relieving symptoms.16
On the whole, the current Malaysian primary health care system is still oriented towards the care of acute, episodic illnesses as well as maternal and child health. Chronic disease management, be it in the public or private setting, is still largely being done in a sporadic, unplanned and uncoordinated manner. Discrete healthcare providers often duplicate laboratory and radiological investigations as medical records are not shared between providers. There is also no regulation that requires patients to be registered with a primary care doctor, thus they tend to move freely, hopping from one doctor to another. This situation, undoubtedly, contributes further to the fragmentation and duplication of care. Previous policy and focus on maternal and child health has resulted in commendable achievements with regards to the increase of life expectancy at birth as well as in reduction in the maternal and infant mortality rates.15 Although the Ministry of Health (MOH) has introduced policy changes pertaining to chronic disease management in primary care in recent years, implementation of successful programmes is hampered by the lack of human resources and inefficient system which remains oriented towards acute care.
FACING THE CHALLENGES: DIRE NEEDS OF PRIMARY CARE SYSTEM REFORM
Numerous high quality and evidence-based chronic disease management models have been developed over the past decade.23-27 The most notable of these models, is the Chronic Care Model (CCM) which has been shown to successfully change healthcare practices for chronic conditions in many developed countries.27,28 In response to the growing chronic disease burden in the low and middle income countries and the ensuing need to help these countries to transform their healthcare systems, the WHO convened the representatives from these countries to expand the Chronic Care Model (CCM) 27 into the Innovative Care for Chronic Conditions (ICCC) Framework (Figure 1) which is more relevant and applicable to the low and middle income countries.23
The ICCC Framework illustrates the complementary nature of working across the disease continuum in a comprehensive way. It centred on the concept that optimal outcomes occur when a health care partnership triad is formed among patients and families, health care teams, and community partners.23 The framework functions at its best when each member communicates and collaborates with the other members of the triad at all levels of care and becomes informed, motivated, and prepared to manage chronic conditions.23 Positive policy environment is paramount and should encircle and support community efforts that are formally connected to health care organisations.23
Both the CCM and ICCC Framework provide specific strategies for creating innovations in the care of chronic conditions. Regardless of resource level, every health system can take action to improve health care for chronic conditions.23 Compelling evidence on successful implementation and quality outcomes of innovative programmes in low, middle and high income countries are available from around the world.29-34 A nurse-led chronic disease management programme for high blood pressure, diabetes, asthma and epilepsy established in a rural South African setting has been shown to improve disease control in 68% of the hypertensive patients, 82% of those with diabetes and 84% of those with asthma.29 An innovative programme that taught physicians new skills in communication and disease management has been shown to improve health status and lower health care cost of low-income asthma patients.31 In resource-poor setting of Peru and Haiti, patients with little formal education and few material resources can successfully manage complex medical regimens for drug-resistant tuberculosis or HIV/AIDS when provided with self-management support and careful follow-up.32
Given the compelling evidence on cost-effective interventions and innovative management of chronic conditions, the failure to use this knowledge to instigate a change in the current primary health care system is unjustified. Both the CCM and ICCC Framework offer specific strategies for creating innovations to transform the care of chronic conditions in the Malaysian primary health care system.
Figure 1. The WHO Innovative Care for Chronic Conditions (ICCC) Framework23 (reproduced with permission from WHO)
Top-down policy change and implementation
Change has to be instigated at all levels from political decision-makers (macro level), health care organisations and community leaders (meso level), and health care personnel, patients and families (micro level). Each group has its own roles and scope of influence. Every person is responsible to become an agent of change. A new paradigm of thinking is needed at all levels for transformation towards care for chronic conditions to be successful, which will fundamentally lead to an informed and motivated partnership among stakeholders at each level.
To be most effective, change should start at the macro level. Measurable improvement in the care of patients with chronic conditions will only occur if system leaders make it a priority and provide the leadership, incentives and resources necessary to make improvements happen.28 Although some efforts and changes has been made by Malaysian policy makers pertaining to primary care management of chronic diseases in recent years, there is still an urgent need to conduct high quality research to study the barriers of implementations in more detail. High level commitment and investment is also needed to ensure successful expansion of the TPC project which would provide data to ensure a fairer distribution of financial allocation guided by disease burden and cost-effective interventions. Although the total primary health care expenditure has consistently increased from RM9.6 billion in 2003 to RM14.2 billion in 2006,13 simply adding capital to an already ineffective primary health care system is not going to significantly improve the quality of care and outcome for chronic conditions.23 Fundamental reform to integrate the public and private primary health care sectors to become one system is crucial before meaningful outcome can be achieved. A policy to produce highly trained and competent primary care doctors and allied health care personnel should also be high on the agenda.
