REVIEW ARTICLE
MANAGING CHRONIC DISEASES IN THE MALAYSIAN PRIMARY HEALTH CARE – A NEED FOR CHANGE
At the meso level, concerted efforts should be made to set up dedicated multidisciplinary care teams for chronic diseases throughout the country. Multidisciplinary healthcare teams, centred on primary health care, has been shown to be highly effective to improve coordination of care, disease control and health outcomes.35,36 The authority needs to ensure that the range of laboratory tests and equipments needed to diagnose and monitor; and the required drugs to control chronic diseases are available in primary care. Expansion of the TPC project is crucial to link all health care providers across sectors. Well-designed, locally relevant and sustainable clinical information systems are essential to achieve the goal of coordinated long term care by creating disease registry, organising patient information, planning and tracking patient care.37 Although locally relevant evidence-based clinical guidelines are already available for most major chronic diseases in Malaysia, they are mainly disseminated to the public primary care sectors. The implementation of such guidelines at the primary care level, especially in the private sectors is still abysmal. Clinical guidelines must be integrated within the structure of day-to-day clinical decision making process to ensure successful implementation.38
At the micro level, it is imperative that health care personnel develop quality long-term relationships with patients and their families. The traditional role of patients as passive recipients of health no longer holds true and emphasis must now be upon them and their family’s central role to take active responsibility to become an effective partner in managing their conditions.39 Self-management programmes have been shown to reduce the severity of symptoms, improve confidence, resourcefulness and self-efficacy of patients with chronic conditions.40 It should therefore be advocated and supported through effective patient education. Healthcare workers must ensure that patients have adequate information and skills to manage their chronic conditions.
This concept highlights a new paradigm in the current clinical practice and therefore, requires effective communication abilities, behavioural change techniques, patient education and counselling skills of primary care workforce to care for patients with chronic conditions. This underscores training needs in these areas for doctors, both at the undergraduate and postgraduate level, as well as for the allied health care personnel.
Development of human capital – addressing training deficiencies
Currently, almost all of the public and private universities in Malaysia have integrated Primary Care/Family Medicine training in their undergraduate curriculum. However, there should be a greater emphasis to highlight the escalating chronic disease burden and the concept of chronic disease management in the undergraduate primary care curriculum. Great emphasis should also be placed on communication skills and consulting skills training, which includes patient education and counseling throughout the undergraduate and postgraduate curriculum.
Rigorous call should be made for more medical graduates to specialise in Family Medicine to address the current shortage of FMS. Until recently, the Masters in Family Medicine (MMed Family Medicine) offered by three public universities was the only recognised specialist qualification for Family Medicine in Malaysia, while the recognition of vocational training programme for private primary care doctors leading to the joint Membership of Academy of Family Physician Malaysia (MAFP) and the Fellowship of Royal Australian College of General Practitioners (FRACGP) had been protracted over the last 30 years. The year 2007 has finally seen this key milestone being accomplished when this qualification received its recognition from the Family Medicine Specialty Subcommittee of the National Specialist Register.17 This highly overdue recognition, together with the personal-to-holder recognition of the Membership of Royal College of General Practitioners, United Kingdom (MRCGP, UK) is seen as a great step in the right direction in the struggle to overcome the acute shortage of Family Medicine Specialists and the strive towards a seamless care between the public and private sectors.
Although postgraduate specialist training in Family Medicine has long been available, a large number of primary care doctors are still untrained as legislation does not require a postgraduate qualification before entering into primary care practice. The Academy of Family Physician Malaysia (AFPM) has been given the task to undertake a 2-year Diploma in Family Medicine Course for all private general practitioners, which will commence in 2009.17 Ideally, this training should be government-funded and made compulsory to all primary care doctors. The public, private, and academic primary care sectors should rally to form a national committee on postgraduate training and actively participate in this key programme to ensure that all future generations of primary care doctors are well trained to face the growing primary care challenges including the challenge of managing chronic conditions.
Availability of trained allied health care personnel is also critical to support successful implementation of chronic disease management programmes. There should be a constant endeavor to increase the number of trained nurses and other allied health care personnel for chronic disease care, while incessantly improving the skills, knowledge and attitude of all primary health care workforces to deal with the challenge of chronic disease management through continuous professional development training courses.
Integration of public and private primary health care sectors
The integration of public and private primary care sectors in Malaysia should be high on the agenda of policy change. Care for chronic conditions needs coordination and continuity across time and health care setting, and across sectors. Traditional boundaries among levels of the system of primary, secondary and tertiary care, as well as across public and private sectors must be minimised to allow better integration to occur. Malaysia has a limited number of Family Medicine Specialists, but a large number of private general practitioners. Seamless integration and collaboration with the private primary care sector is crucial to optimise the use of available human capital to care for chronic conditions.
The proposed National Health Financing Scheme (NHFS),41,42 with its core objective to provide universal coverage and equitable access to both the public and private health sectors, could provide an ideal platform of integration between the public and private primary health care. The Malaysian Medical Association (MMA) advocated that the NHFS should be corporatised and government-run, but it should never be privatised. It is anticipated that primary care doctors with postgraduate qualification will receive a higher remuneration under the NHFS compared to those without further training. This will indirectly induce demands on all primary care doctors to undergo postgraduate training in Primary Care.
Comprehensive benefit packages should be developed under the NHFS which include preventive care services, self-management support, chronic care and rehabilitative care services. The TPC project can ideally provide the information based on Adjusted Clinical Groups (ACG) needed to develop fair remuneration packages for the NHFS.16 The NHFS should embrace a fair competition between the public and private primary care sectors based on access, service and quality. Quality assurance and improvement programmes which have already been advocated by the MOH and AFPM, should be integrated within the NHFS. Institutionalised system of quality assurance, which include ongoing clinical audit has been proven to be an effective tool to improve quality and outcomes.43 Financial incentives for improved performance that ties in with quality outcome should also be introduced in the NHFS. The United Kingdom stands out as a leader in this regard where the introduction of financial incentives has been shown to be associated with substantial quality improvement for the incentivised conditions.44,45 It is also timely that legislation should be passed to require patients to be registered with one primary care doctor to facilitate effective coordination and continuity of care. This measure will also reduce wastage of resources as well as enhance comprehensive primary care delivery.
