Primary healthcare (PHC) is defined as “essential healthcare 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.
“It is the first level of contact of individuals, the family and community with the national health system bringing healthcare as close as possible to where people live and work, and constitutes the first elements of a continuing healthcare process.”
It is universally accepted that about 90% of a person’s health needs across his or her lifetime can be covered by PHC.
PHC costs considerably less than hospital care, which provides secondary and tertiary care.
Primary care system
The PHC system in Malaysia is a mixed one, with about 2,900 public facilities and 7,000 private facilities involved in service provision.
The public sector has an extensive network of health clinics, community clinics in rural areas, 1Malaysia clinics in mainly urban areas, and mobile clinics for remote areas, spread throughout the country.
It provides about 60% of outpatient care and accounts for about 35% of total expenditure on primary care.
The private sector, which is clustered in urban and semi-urban areas, provide about 40% of outpatient care and accounts for about 65% of total expenditure on primary care.
The case mix in the public sector is predominantly chronic illnesses, and maternal and child health conditions, in contrast to the private sector, which is mainly acute conditions.
There are geographic variations in the provision of, and access to, health services with different populations effectively having access to different healthcare services depending on location.
The private sector is primarily financed through direct out-of-pocket payments from patients, with some share from private insurance or employer-based group insurance.
Consultation and procedure fees are regulated by the Private Healthcare Facilities and Services Act.
There is, however, no control on the total expenditure per visit or admission to a private healthcare facility.
Although Malaysia is committed to providing health for its rakyat, there have been few reports on the state of PHC in the country.
Harvard group report
The Harvard group, in its report to the Health Ministry, stated that there were “significant and growing gaps in progress on improving overall health outcomes.
“These gaps are visible in slowing rates of improvement in indicators such as child mortality, infant mortality and maternal mortality, and are even more evident in the limited gains in adult life expectancy beyond age 30 and 60, where data show slower rates of change than in higher-income comparators.
“Given Malaysia’s younger population, one would expect faster rates of improvement in life expectancy at age 30 and 60.
“These worsening trends can be linked to significant gaps in screening and treatment for NCDs (non-communicable diseases) such as hypertension, diabetes mellitus and hypercholesterolemia, and in addressing rising rates of key risk factors that can be expected to lead to future increases in NCDs.”
The report went on to say: “Dissatisfaction is evident with some key service-related aspects of government service delivery such as long waiting times, privacy and choice, while in the private sector, there is dissatisfaction due to high charges for services … limited access to more comprehensive primary care services in the government delivery system, including effective treatment and management of NCDs.”
There were access and quality issues with the “right services either not provided or may ultimately be provided sub-optimally and not in the right locations, e.g. in a higher-level facility rather than in primary care.”
The “service quality of government health services has not kept pace with the expectations of citizens, who increasingly demand choice, personal attention, privacy and rapid response to their needs.
“Consequently, many patients turn to private sector services.”
Chasm in primary care provision
A research team from the Health Ministry and Universiti Malaya conducted a national cross-sectional survey of 316 and 597 private primary care clinics from June 2011 through February 2012, using a questionnaire developed based on the World Health Organization (WHO) toolkits on monitoring health systems strengthening.
They “examined the availability of primary care services/resources and the associations between service/resource availability and clinic ownership, locality and patient load.
“Data were weighted for all analyses to account for the complex survey design and produce unbiased national estimates.”
The findings reported that the “private primary care clinics and doctors outnumbered their public counterparts by factors of 5.6 and 3.9, respectively, but the private clinics were significantly less well-equipped with basic facilities and provided a more limited range of services.
“Per capita densities of primary care clinics and workforce were higher in urban areas (2.2 clinics and 15.1 providers per 10,000 population in urban areas versus 1.1 clinics and 11.7 providers per 10,000 population in rural areas).
“Within the public sector, the distribution of health services and resources was unequal and strongly favoured the urban clinics.
“The rural clinics had lower availability of services and resources after adjusting for ownership and patient load, but the associations were not significant except for workforce availability.”
The authors concluded: “Targeted primary care expansion in rural areas could be an effective first step towards achieving universal health coverage, especially in countries with limited healthcare resources.
“Nonetheless, geographic expansion alone is inadequate to achieve effective coverage in a dichotomous primary care system, and the role of the private sector in primary care delivery should not be overlooked.”
The PHC approach is the foundation to the achievement of the shared global goals in universal health coverage and the health-related Sustainable Development Goals (SDGs) to which Malaysia is committed.
The Health Ministry’s commitment to PHC and its thinking on the role of the private sector, if any, have yet to find its way into the public domain.
Its silence on the political commitment to the Declaration of Astana to which it is a party, is, to say the least, surprising.
Clarity on this fundamental issue would be necessary for all stakeholders to move forward.