The 19th Family Medicine Scientific Conference 2016, 10-13 August 2016 with the theme “Excellence in Primary Care; Make It Matter, Make it Better” was held at Grand Dorsett, Subang. It was well attended by almost 700 participants which includes Family Medicine Specialists, GPs, Medical Officers, Public Health Physicians and other health professionals.
It is my pleasure to welcome all participants from all over Malaysia to this 19th Family Medicine Scientific Conference. It is a great honour for me to be here today to officiate this conference and I would like to thank the organising committee for inviting me.
Primary care is an important aspect of health care in a country’s health system. Many developed countries contributed substantial proportion of their health care expenditure to the primary care. Australia for instance, spent almost equal amount of their healthcare budget to the primary care as compared to the secondary and tertiary care in the hospitals.
Over the past 3 decades, many aspect of primary healthcare has evolved in Malaysia. Realising its importance, the government has spent more investments into the primary care as we move towards making primary care as the thrust of the health care system; in order to uplift further the health status of the nation. Primary care in Malaysia has started its services way back in 1950s. At that point of time, the focus was mainly on the maternal and child health with basic infrastructure and human resource. In the earlier years, the main bulk of the healthcare system was largely focused on the curative components of healthcare which are largely based in the secondary and tertiary care in the hospitals.
Under the 10th Malaysia Plan, the government has initiated 4 key initiatives which focus on:
(1) transformation of the health system;
(2) increasing the quality, equity and accessibility of health services;
(3) shifting the focus on prevention rather than curative; and
(4) increasing the quality of the health human resource.
Efforts have been made to improve the accessibility to quality primary care especially to the underserved areas in both urban and rural areas.
Today in Malaysia we can see that remote areas too enjoy accessibility to healthcare, albeit to basic health care. About 10 days ago, I visited Pulau Aman in Penang State which is about 30 minutes boat ride from the Penang Island. Despite having a population of just 187 people, MOH strived to provide health service there. We have a Klinik Desa in Pulau Aman that has been managed by 2 nurses, and I was glad to see that they kept good record of health status of the islanders in Pulau Aman. They run the full national vaccination programme for 25 school children there, and I was glad to be informed that the immunisation coverage there is 100%.
In the 11th Malaysia Plan, the government plans to continue to provide the universal access of quality healthcare to the community. To date, there are 966 health clinics, 100 maternal and child health clinics, and 1,806 community clinics all over the country. Soon there will be a Super Type 1 Clinic called Kuala Lumpur Health Clinic in the city of Kuala Lumpur with extensive building that will be offering primary healthcare services for the surrounding community. The development of new facilities also takes into account the functionality, cost effectiveness and health needs of the local population.
However, massive, extensive and impressive clinic buildings does not guarantee improved health service delivery in primary care. More importantly is the capacity building of its health human resource. This without a doubt is an important component that need to be developed in parallel with facility planning. I am glad to see that our local Master program in Family Medicine that was started initially in Malaya University in 1993 has now been expanded further to include 5 other public universities. Until this date, we have 294 gazetted Family Medicine Specialists in the Ministry of Health and more than 100 Family Medicine Specialists working in various local universities. The Academy of Medicine has also offered a parallel programme to train more Family Medicine Specialist for the country, whereby it offers postgraduate diploma program and MAFP /FRCGP to encourage more doctors to pursue their postgraduate career in this field. Until 2014, we have 340 primary care specialists with FRACGP qualifications in the private sector.
Apart from training the doctors, other health professionals for instance the paramedics have also been trained to have specialised skills in various disciplines like diabetes educators, HIV counsellors and many others. The Ministry of Health is also getting more dieticians, nutritionists, physiotherapists, occupational therapists, social welfare officers and psychologists to complete the team in the primary care.
We have heard many success stories about the achievement and progress made in primary health care in Malaysia. They were all achieved through comprehensive planning, networking and collaboration between various stake holders. However, the gained made in the last 3 decades has now plateaued. Further gain has proven to be difficult to achieve, and we are not left without new challenges in our health system.
Today we are challenged with double disease burden; by both Communicable Diseases and Non-Communicable Diseases.
Diabetes for instance; through the National Diabetes Registry, we now have better access on the information of performance of our health clinics in terms of care for the diabetics. Through the annual Clinical Diabetes Audit, we can see improvements in the percentage of those reaching target HbA1c (HbA1c less 6.5%) from 19% in 2009 to 23% in 2012. In terms of treatment, larger percentage of patients received insulin therapy in 2012 compared to 2009, which signify the success in educating the doctors to treat patient more diligently.
However the recent findings from National Health Morbidity Survey (NHMS) 2015 showed increasing prevalence of diabetes, whereby almost 1 in 5 adults aging 30 years and above are diabetics. More worrying is that, not only that the prevalence were high but about 50% of these diabetics were actually undiagnosed. That means, about 50% of adult diabetics in Malaysia do not actually know that they have diabetes. Literally, 1 out of 10 of us Malaysian adults has diabetes and he/she does not even know it! To add to that, Malaysia is the most overweight nation in Southeast Asia with 44.2% of our adults in 2011 are overweight.
Therefore, more work has to be done to screen and diagnose people early to prevent later complications. Healthy lifestyle has to be promoted and living healthily should be made a trend especially for our younger generation. Thus I urge the primary care providers to double your efforts in early detection, health promotion and preventive activities. One of the initiatives by MOH to address this is by initiating the community program Komuniti Sejahtera Perkasa Negara (KOSPEN) to various communities to promote healthy life style.
Another important initiative at health clinics is the introduction of the Family Doctor Concept (FDC) led by the FMS in various parts of the country. This has also been introduced in stages to provide a holistic and comprehensive care to the patient via a model of a patient-centred and integrated care. With this initiative, it is expected that the chronic disease management of a patient and his family as well as the community would see further improvement. I visited Klinik Kesihatan Penaga during my recent working visit to the Penang State where I was briefed on the progress made by our FMS in expanding this Family Doctor Concept there. I was pleased to be informed that this concept received good feedback from patients and our ground staff.
We are also facing challenges with the maternal and child health. Whilst we thought mothers dying from unsafe home deliveries and children dying from infectious diseases were relic of the past, we are now seeing the re-emergence of unsafe deliveries and children dying from vaccine preventable infections.
In the past, one of the main reason for maternal mortality is because of the unsafe deliveries conducted by untrained personnel. We then trained the traditional midwives and get them to be ‘registered’ with us. We also built Alternative Birthing Centre (ABC) in some of our health clinics to give better access to safer birthing practice, especially for those in remote areas to allow them to deliver their babies in a safer environment. But now we are getting parents and women who made decision to give birth at home ‘naturally” without any help from the trained midwives or doctors.
We also introduced immunisation to help overcome the morbidity and mortality of our children related to vaccine preventable diseases. In fact immunisation has been well regarded as the second most successful public health intervention after sanitation that has helped save countless life, not only in Malaysia but also throughout the world. For many years our immunisation coverage has been said to be excellent, reaching more than 95%. But of late, the number of mothers and parents that refused to vaccinate their children has started to increase. This is truly concerning. We often hear about anti-vaccine group and we are all aware these groups influence other parents through social media.
For the good and the worse, the public including parents are getting information at their fingertips. News spread within seconds like wildfire. Unfortunately there are many false information placed on the social media and our mother/parents/communities are getting the wrong information and can be misguided by netizens that misuse the social media. Surely there are other causes of infection outbreaks such as diphtheria and measles. However it is rather evident that this anti-vaccine movement has contributed largely to this sad and gruesome outcome: the re-emergence of vaccine preventable diseases which we previously only heard in medical text books.
We really need to win this battle again. Primary care whether in public and private, need to work harder and empower the community especially young parents with the correct knowledge and information. Our voice has to be louder than those abusing the social media and mislead our community. We have to be proactive and persistent in empowering knowledge via the social media. Recently I helped launch a Facebook page called the Medical Mythbusters Malaysia which was created by our fellow doctors, pharmacist and paramedics. Their aim was to help empowering the public with correct information in a professional manner and to literally “bust the myth” related to health issues. This is certainly not the only way to address this issue, but surely can help to guide the public to the right path of living healthily. Of course, there are certainly many other areas that we have to look into to comprehensively and effectively address this issue.
On the other hand, we are still challenged with the HIV infections in this country. I am glad that we have managed to reduce HIV infection rate by half, falling from 21.8 per 100,000 in the year 2000 to 10.9 per 100,000 population in the year 2009. Primary healthcare had contributed largely in this reduction through its harm reduction program (methadone therapy, needle exchange, Prevention of Maternal to Child Transmission program) and access to treatment of HIV drugs at primary care clinics with Family Medicine Specialist services. Even though we have made impressive progress on some of the areas in combating HIV infections, there are now new challenges in this area whereby we are noticing a change in the epidemiological demography of HIV infections. The mode of transmission of HIV among the newly diagnosed HIV patients has shifted from needle sharing for among Intravenous Drug Users (IVDU) to sexual transmission. In 2010, the percentage of mode of transmission between IVDU and sexual transmission was almost equal. However in 2014, 78% of the HIV transmission were from sexual activities, whereby 28.3% were due to homosexuality practice. This is indeed a very concerning finding, and it requires multidisciplinary effort to address this holistically.
Through National Strategic Plan Ending AIDS (NSPEA) 2016-2030, we aspire to achieve the 95-95-95 target, of which:
- 95% of key populations tested for HIV and know their results,
- 95% of people infected with HIV placed on Anti-Retroviral Therapy (ART), and
- 95% of these adhering to treatment with suppressed viral load.
The commitment includes reaching 90% of the key populations with effective prevention. Primary care initiatives are important in the overall plan to achieve this.
What I have mentioned here are just some of the examples of the progress that we have made and some of the challenges that are being encountered in the primary care system of Malaysia. Definitely this system can be further strengthened by effective public-private partnership as private clinics certainly served a significant portion of the primary care health facilities in the community. It is important for the private primary health care providers to also update themselves in the recent advances of medical management. I hope conferences like this can be utilised to address the gap between private and public practitioners. Here, the private practitioners can join the public Family Medicine Specialist and practitioners to communicate, build bond, establish rapport and collaborate to form cohesion in working together as a nation for better health.
Apart from updating the participants with latest and new information on medical knowledge, it is hoped that this conference serves as a platform to share research and studies done at individual localities. I certainly am pleased to see more research has been done at our MOH clinics, and would encourage all of you to publish your good work in local, regional and international journals so that the works done in the primary care are made visible.
I would like to congratulate Family Medicine Specialist in Selangor, Family Medicine Specialist Association and the Selangor State Health Department for their hard work in organising this event. I hope all of you will take this golden opportunity here to garner knowledge via the organised scientific programme and talks given by distinct international and local speakers. Hopefully this conference will be able to boost your motivation to strive further in improving the primary healthcare system in this country. May all the objectives be achieved and to all the participants have a fruitful conference.