When Malaysia was first formed 55 years ago, our biggest healthcare problems were infectious diseases, and maternal and infant mortality.
Over the last several decades, we have not only tackled these problems, but exceeded global standards in doing so.
Maternal mortality, which is the death of a woman caused by her pregnancy or its management, decreased by 89% in the period of 1963 to 2013, from 210 deaths per 100,000 live births to 23.2 deaths.
Infant mortality, which is the death of children under one year of age, decreased by over 90% in the period of 1957 to 2013, from 75.5 deaths per 1,000 live births to 6.5 deaths.
Meanwhile, through the National Immunisation Programme (NIP), a number of infectious diseases that had a very high burden of illness or disability, and death, during their heyday, have either been eliminated or brought under control.
Smallpox was the first disease a vaccine was provided for by the then-Malayan Government in the early 1950s.
While the World Health Organisation (WHO) declared the world smallpox-free in 1979, Malaysia had already eradicated the disease from its shores the year before.
The introduction of the polio vaccine in 1972 resulted in the country being declared polio-free in 2000 by WHO, while the fight to completely eradicate polio from the world is still ongoing in Pakistan, Afghanistan and Nigeria – the last three countries in the world that still have polio infections.
Meanwhile, neonatal and maternal tetanus have practically been eliminated in the country, with less than 20 cases of neonatal tetanus occurring on average per year among illegal immigrant families in Sabah.
Tetanus is one of the three infectious diseases covered by the DPT (diphtheria, pertussis, tetanus) vaccine given to children under the NIP. Pregnant women are also given the tetanus vaccine under the programme.
The DPT (also known as DTaP) vaccine was the second compulsory vaccine to be introduced in the country in the late 1960s, and has also contributed to the current low rates of diphtheria (0.1 cases and 0.02 deaths respectively per 100,000 population) and pertussis, or whooping cough (0.94 cases and 0.01 deaths respectively per 100,000 population), in the country.
Hepatitis B cases have also come under good control with only 0.3% infections among the vaccinated population, compared to a rate of 1.9% to 3% in unvaccinated populations.
In addition, the NIP provides coverage against tuberculosis (BCG vaccine); measles, mumps and rubella (MMR vaccine); Haemophilus influenzae type B (HiB); Japanese encephalitis in Sarawak, where it is an endemic problem; and human papilloma virus (HPV) infection for girls.
All the NIP vaccines are compulsory and provided for free at public clinics and hospitals.
As the vaccines, which are all imported, cost the Health Ministry around RM130mil a year – which does not include the cost of consumables, like syringes, and human resources – the Government is collaborating with a multinational company to produce vaccines locally in Malaysia.
However, it is expected to take a number of years before these vaccines are available as they need to undergo clinical studies and registration before they can be used.
While the fight against infectious diseases has gone well, Malaysia is now facing a new battlefront in non-communicable diseases (NCDs) – and we are currently losing.
According to the Malaysia Health Systems Research Volume 1 report, in 2013, NCDs accounted for just under three-quarters (72%) of the burden of disease in the country.
From 2006 to 2015, as seen from the relevant National Health and Morbidity Surveys (NHMS), cases of diabetes mellitus increased over 50% and high cholesterol levels (hypercholesterolaemia) doubled in Malaysians aged 18 and above.
Cases of high blood pressure, or hypertension, dropped over the same period, but was still present in just under one-third (30.3%) of adults.
More worrying, however, is that over half of those with diabetes and high blood pressure are unaware they have those conditions.
This number was even worse among those with high cholesterol levels, with four out of five unaware of their unhealthy cholesterol levels.
This is exacerbated by the fact that 98% of Malaysian adults have at least one risk factor for NCDs, and a large number of us have multiple risk factors, like smoking, an unhealthy diet and lack of physical activity, as stated by the Malaysia Health Systems Research report.
To that end, the Health Ministry piloted the Enhanced Primary Health Care (EnPHC) programme in July 2017 in 20 public health clinics (klinik kesihatan) – 11 in Johor and nine in Selangor.
This programme is meant to tackle the NCD problem at its source, by promoting preventive efforts, empowering each individual to take control of their own health and wellness, increasing rapport between patients and their primary care doctors, and ensuring a seamless transition of care for each patient between Health Ministry hospitals and clinics.
One method is by attempting to register all those living within the operational area of each clinic, along with their basic health information.
This is in order to monitor their health status and risk factors for NCDs, and initiate preventive or treatment efforts when necessary.
For this pilot programme, the focus is limited to three crucial conditions: diabetes, hypertension and hypercholesterolaemia.
Individuals found to be at risk of any of the conditions will be given the appropriate counselling, e.g. dietary advice or exercise guidance, while those diagnosed with the condition will be started on a treatment regime.
Patients and their families will also be assigned to specific health teams lead by a doctor under the Family Doctor concept.
In this manner, health problems can be more easily detected as the patient is being continuously seen by the same healthcare professionals.
Doctors, nurses and other members of the healthcare team will also be able to establish better trust and rapport between themselves and patients and their families, which will greatly help in optimally managing their health.
Patients can also be easily referred to a hospital if necessary, and followed up at the clinic upon their discharge. This will help ensure a seamless continuity of care between primary (clinics), and secondary and tertiary healthcare centres (hospitals).
Currently, the initiative is with the patient to attend referral and follow-up sessions, and some fail to do so, exposing themselves to developing complications and further burdening the healthcare system.
The Malaysia Health Systems Research report also states that around 15%–20% of hospital admissions are for conditions that should actually be managed by clinics.
This reflects an inefficiency in the system that the EnPHC programme is trying to address.
While there are many challenges to implementing the programme nationwide, not the least of which is manpower, the idea behind the pilot programme is to identify those challenges and working out solutions to them.
The programme is expected to be expanded to more health clinics around the country in 2018.
Another problem associated with NCDs is the need for long-term home care for bed-ridden patients.
The Domiciliary Healthcare Service (DHS), which was introduced in 2014, is based out of 160 health clinics around the country.
Patients who live within the operational areas of these clinics can request for this service, which provides home visits by nurses, medical assistants and other allied health professionals.
These DHS teams aim to help monitor the patient’s health status, as well as educate their caregivers on how best to care for them.
For example, they teach caregivers how to carry, position and exercise immobile patients; care for wounds; and provide dietary advice and welfare support, if necessary.
The service is based on the medical requirements of the patients and covers those discharged from public hospitals.
Up to January 2018, they have served 8,302 patients, 70% of whom are elderly. Most of these patients have either stroke or spinal cord injuries that render them bedridden.