Prioritising primary healthcare as the first line of defence

A good primary healthcare network can help decrease the overall burden on the healthcare system as it serves as the first line of defence against various diseases. — IZZRAFIQ ALIAS/The Star

There has been much public discussion about the increased premiums for private health insurance.

One of the remedies proposed is increased utilisation of primary health care (PHC).

Today’s column intends to provide background information to the public for more informed discussion.

Defining primary health care

The Alma Ata Declaration of 1978, which was endorsed by all member states of the World Health Organization (WHO) defined PHC 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 country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination”.

Since then, the definition has undergone reinterpretation and redefinition.

The current WHO definition is: “PHC is a whole-of-society approach to health that aims at ensuring the highest possible level of health and well-being, and their equitable distribution, by focusing on people’s needs and as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people’s everyday environment.”

The components of PHC are:

• Comprehensive integrated health services that embrace primary care, as well as public health goods and functions as central pieces
• Multi-sectoral policies and actions to address the upstream and wider determinants of health; and
• Engaging and empowering individuals, families and communities for increased social participation and enhanced self-care and self-reliance in health.

PHC is founded on social justice, equity, solidarity and participation, i.e. the recognition that the highest attainable standard of health is one of the fundamental rights of every human being.

There is global evidence that investments in PHC improve equity, access, healthcare performance, health systems accountability and health outcomes.

There is also clear evidence that factors outside the health system are critical influences on health and well-being.

Another common term used is “universal health coverage” (UHC).

This is defined as “all people hav(ing) access to the full range of quality health services they need, when and where they need them, without financial hardship.

“It covers the full continuum of essential health services, from health promotion to prevention, treatment, rehabilitation and palliative care”.

Private and public clinics

According to the Health Ministry’s (MOH) Health Facts 2024, there were 10,495 registered private medical clinics and 3,114 public Klinik Kesihatan (KK), as of Dec 31, 2023.

The latter consisted of 1,095 health clinics, 1,716 rural clinics, 80 maternal and child health clinics, and 223 community clinics.

In short, private medical clinics exceeded KKs by 337%, i.e. for every KK, there were 3.37 private medical clinics.

PHC is provided by general practitioners (GPs), who make up the vast majority of those running private medical clinics, and by the various healthcare professionals i.e. doctors, nurses and midwives, in the KK.

Like the KK, the private clinics are varied – some are group practices, while others are solo practices.

The group practices are akin to those of the public health clinics, offering a range of services.

The solo practices have a more limited range of services.

Almost all the KKs are open during office hours only.

Most of the private clinics are open on weekends and public holidays, and some for 24 hours a day.

Using data collected in the Malaysian International Quality and Costs of Primary Care (QUALICOPC) study conducted in 2015–2016, a research team from the MOH’s Institute for Clinical Research reported in the PLOS One journal in Oct 2022 that: “The public sector was shown to have higher performance in comprehensiveness and coordination, while the private sector was better in continuity.

“There was no significant difference in accessibility.

“The public primary care services were better in serving primary care sensitive conditions, better informational continuity, and with better skill-mix and inter- and intra- professional relationship.

“Meanwhile, the private sector was stronger in referral decision-making process, specialist feedback and greater out-of-hours facilities access.”

The authors concluded: “The public and private sectors differ in their strengths, which the government may tap into to strengthen primary care services.

“Other areas for improvement include seamless care strategies that promote good referral, feedback and information continuity.”

Free and fees

PHC services in the public sector are virtually free.

Meanwhile, the 2006 Fee Schedule of the Private Healthcare Facilities and Services Act limits private GPs’ professional fees.

The charges for private PHC services are bundled, unlike that in private hospitals.

For example, a person with an upper respiratory infection will be charged a composite fee by a GP, but in a private hospital, there will be separate charges for registration, consultation, investigations (if any), medicines, nursing and other services.

Private PHC payments are usually out-of-pocket, via insurance or through employer schemes operated by third party administrators (TPA), which are for-profit organisations.

TPAs, which have been in Malaysia for about two decades, and insurance companies, have increasingly intruded into PHC practices by paying very low medical consultation fees, limiting investigation(s), and dictating the types and methods of treatment.

A study of 1,800 private GP practices in Peninsular Malaysia, published in 2017 in the International Journal of Public Health Research revealed that “the expenditure of managing GP services has increased over the years due to the changes in policies. as well as the involvement of third-party administrators in the healthcare system...”

Steps for sustainability

PHC is the first line of defence in disease progression with a focus on preventive care, early diagnosis and effective management of non-communicable diseases (NCDs).

PHC can significantly reduce the need for expensive hospital treatments and specialist care.

This will minimise increases in healthcare costs.

The consequences of overlooking PHC include, among others, unmanageable healthcare costs in the public sector, increased insurance premiums in the private sector, and worsening health outcomes.

To ensure that the healthcare system is sustainable, the measures that have to be taken include:

• Increasing funding for healthcare, particularly PHC, to enhance infrastructure, improve service delivery and access, particularly in the public sector.

   

  The public sector expenditure on healthcare has to be increased from its 52.7% of Malaysia’s total expenditure on health (TEH), which was RM84,192mil in 2023.

  In addition, PHC expenditure has to be substantially increased from 27.2% of the TEH in 2023.

• Expanding public-private sector partnerships by collaborations with GPs to enhance accessibility and continuity, reduce the burden of managing uncomplicated NCDs in the public sector, and improve efficiency in service delivery.
• Empowering GPs with the removal of restrictions from regulatory and payer perspectives.

Our MOH’s policies that micromanage medical practice have to be removed.

It is time to stop making GPs the boogeymen of failures in public sector service delivery.

There has to be regulatory control of TPAs.

Medical practice has to be in the hands of trained healthcare professionals, not administrators who have little or no idea about the nuances of medical practice.

Concerns about patient safety and quality, if any, can be addressed by guidelines, training and monitoring.

Investing in PHC

Malaysia is committed to achieving the Sustainable Development Goals (SDGs) by 2030.

SDG 3.8 states: “Achieve UHC, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”

PHC is the most effective and cost-efficient way to achieve UHC.

Investing in PHC involves decisions on what to cover based on population needs and available resources.

This ensures that all needs are identified, prioritised and addressed in an integrated manner; that there is a resolute and equipped healthcare workforce; and that all societal sectors contribute to confronting environmental and socioeconomic factors affecting health and well-being, including preparation for, response to and recovery from emergencies.

The WHO states: “Primary healthcare-oriented health systems consistently produce better outcomes, enhanced equity and improved efficiency.

“Scaling up primary healthcare interventions across low- and middle-income countries could save 60 million lives and increase average life expectancy by 3.7 years by 2030.” 

Can Malaysia afford not to increase investment in PHC?

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email [e-mail]. The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only, and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.