The Government states that it subscribes to universal health coverage (UHC), which means that “all people have access to the quality health services they need, when and where they need them, without financial hardships”.
UHC is founded on primary health care (PHC), which is about caring for the person and not the specific disease or condition.
It is a cost-effective, cost-efficient and equitable mode of healthcare delivery.
What is quality?
Everyone has different perceptions of quality, which may not be easy to quantify at times.
Quality of care has been defined as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”.
The fundamental feature of UHC is good quality healthcare. The principles of quality in health systems are transparency, people-centredness, measurement and generation of information, and investment in the workforce, which are all underpinned by leadership and a supportive culture.
An important question is who defines quality primary care (PC).
The easy approach is that quality should be defined by patients and not policymakers, politicians or healthcare professionals, but then who are the representative patients?
There is not much data published on the quality of PC in Malaysia. However, there is data from a 2015 study by the Health Ministry and the TH Chan School of Public Health in Harvard University, published by the Clinical Research Centre.
Klinik Kesihatan findings
The cross-sectional study, from August to October 2015, involved 222 randomly-selected practices in the Health Ministry’s Klinik Kesihatan (Health Clinic) in Selangor, Kuala Lumpur, Kelantan, Sabah and Sarawak.
Doctors, along with 10 of their patients, in each clinic were randomly selected on the day of the study. The patients, aged 18 and above, included Malaysians and non-Malaysians.
The study involved four sets of questionnaires (practice, doctor, patient experience and patient value), which were complemented by structured interviews.
A total of 221 (99.5%) of the clinics/doctors participated in the study.
Of the 2,366 patients seen by the participating doctors, 2,148 (90.8%) completed the designated questionnaire – 1,927 completed the patient experience questionnaire and the remaining 221 patients, the patient value questionnaire.
The patients’ ethnic backgrounds were Malay (52.1%), Iban (7.4%), Dusun (7%), Chinese (6.4%) and Indian (5.1%).
Most of the patients were of lower socio-economic status, with about 43% housewives, 26.9% employees and 22.9% self-employed.
About 80% of the patients indicated that they never postponed or abstained from consulting a doctor when they needed to.
Of the 347 patients who delayed seeking care, 11.6% and 7.2% gave physical and financial reasons respectively for the delay.
The average (median) travel time from the home to the clinic was about 10 minutes, irrespective of the mode of travel.
However, 7% of the patients took more than one hour to reach the clinic, of whom 74.9% were in Sabah and Sarawak, which was due to the lower density of clinics in those states.
The waiting time overall was less than 30 minutes for 41.4% of the patients and more than an hour for 37%.
Longer waiting times were more common in urban clinics, compared to rural clinics (43.5% versus 31.3% respectively). Most of the patients (96.7%) reported satisfaction with the duration of the consultation.
More than three-quarters of the doctors reported frequent involvement in managing uncomplicated type 2 diabetes and acute/chronic pulmonary conditions.
However, more than half reported that they rarely managed conditions like depression and rheumatoid arthritis.
Common procedures carried out were setting up intravenous (IV) infusion and wound suturing.
The excision and cryotherapy of warts, removal of sebaceous cysts and joint injections were rarely performed in more than three-quarters of the clinics.
There was routine measurement of blood pressure in 86.9% of clinics. However, there was routine blood cholesterol measurement in only one-fifth of the clinics.
About 90% of the doctors reported engagement in health education for smoking cessation, diet and exercise as part of their normal patient encounters.
However, only about a quarter were involved in group education for the same topics.
About half (43.9%) were not involved in alcohol-related health education.
More than 80% of the doctors routinely documented the following in patient records (in descending order of frequency): blood pressure, prescribed medications, test results, diagnosis, ethnicity, reason for encounter, weight and height, family history and smoking status.
The patients’ living situation was routinely documented by only half (46.6%) of doctors.
There was a marked lack of longitudinal continuity of care, as 84.8% of the patients did not have a regular doctor they would always see.
The study authors stated “the family doctor concept is only now being introduced into the public primary care clinics in phases in an effort to provide continuity of care for chronic diseases”.
The relational continuity results were mixed. Although 82.3% of the patients reported that the attending doctor was aware of their important medical information, 53.8% felt that the doctor did not know about their living situation.
Direct contact with other healthcare professionals in PC settings were reported by 90% of the doctors.
However, contact with other healthcare professionals, especially those working at higher levels of care, were less frequent, with 58.4% of doctors reporting that they seldom or never met a hospital specialist, 58.8% seldom or never meeting an ambulatory specialist and 72.4% seldom or never meeting a social worker.
Coordination between PC practices was lacking, with 51.6% of doctors reporting that they occasionally received new patients’ medical records from their previous doctors and 36.2% reporting that they usually received the medical records.
Coordination between primary and secondary/tertiary care was very infrequent in some specialities, with more than half of PC doctors never or seldom seeking advice from surgeons, psychiatrists, radiologists, dermatologists, neurologists and geriatricians.
However, more than 60% of doctors reported frequent consultations with gynaecologists, physicians and paediatricians.
Letters, with details on provisional diagnosis and test results, were used by 99.1% of doctors in referrals to higher levels of care.
About half (50.2%) of the doctors reported that they seldom or never received any feedback from the specialists to whom they referred their patients.
More than half (58.4%) rarely or never received a hospital discharge report and only 27.6% received such a report within a fortnight.
Family doctor concept needed
Some of the findings from the report were positive.
However, the authors also concluded: “There was a lack of longitudinal continuity and coordination of care in PC, as the current organisation of public PC clinics does not support the patients to have their own doctor whom they usually visit for a health problem.
“While personalised care for maternal and child health services is being delivered by the nurses in the PC setting, the family doctor concept is only now being introduced into the public PC clinics in phases, in an effort to provide continuity of care for chronic diseases.
“Until the concept of the family doctor is adopted widely, the problems in continuity and coordination will be hard to rectify.”
As continuity and coordination are critical to the provision of healthcare, Health Ministry clinics have a long way to go in delivering quality PC nationwide.
Had the same study been done in private primary care or general practitioner clinics, it would have provided useful comparative data for decision-making.