Malaysiakini Letter

Urgent need for primary care reform

Yogarabindranath Swarna Nantha  |  Published:  |  Modified:

‘A fire can be seen at great distance, when it gives not heat’ – Publius Syrus

LETTER | The Ministry of Health has outlined several strategies to optimize the healthcare services in the country. The policies proposed in this article calls for structural changes in the pre-existing infrastructure to uplift the standards of our healthcare delivery system.

Kudos to our new Health Minister Dzulkefly Ahmad for taking the step in the right direction to solve the problems of most patients seeking health services at government hospitals.

However, in the true spirit of much-needed reform in this country, I beg to differ with the approach adopted by the ministry for two glaring reasons:

1. The approach is far too mainstream and

2. The strategy overlooks the importance of both public health and primary care services in this country.

The new policies reflect the mainstream response to this type of problem which continues to neglect the importance of synchrony between primary care and other services. While I earnestly believe that these newly minted policies are not etched in stone, subsequent revisions should reflect dynamism by recognizing the importance of preventive medicine in ensuring overall health status of the nation.

Evidence from the Starfield Report (Starfield, 2005) has conclusively demonstrated that primary care helps in preventing illness and death. Also, primary care services are also associated with an equitable distribution of health in the population (Starfield, 2005).

Furthermore, there has been an upsurge in the burden of non-communicable diseases (NCDs) in the country, contributing to approximately 73% of the total deaths within the productive age group (National Health and Morbidity Study, 2015). These alarming trends have prompted some researchers to advocate cost-efficient and practical solutions to ameliorate NCDs via improvements in primary care and public health services in Malaysia (Swarna Nantha, 2014).

Allow me to succinctly highlight three significant problems areas that the ministry should focus on at present:

1. Training of primary care doctors

In line with most developed nations, the ministry should streamline the oversight of family medicine training under a single professional membership body tasked with the responsibility of designing suitable training programs, supervising general practitioners and ensuring all members adhere to a strict set of ethics throughout their career.

In Malaysia, there is a widespread discrepancy between the various modalities designed to produce primary care doctors in the country. Local universities (with differing curriculum and education standards) offer training for candidates vying for family medicine specialization.

The number of doctors selected for this pathway remains relatively low given the number of training posts available at the university. Alternatively, the Academy of Family Medicine Malaysia and the Royal College of General Practitioners in Australia have developed a conjoined training program tweaked to match the standards of the programs espoused by local universities.

Hence, the training of family medicine specialist appears to be under the supervision of two different professional bodies with reasonably different curriculum with varying levels of exposure to research, workplace-based training and number of student intake per semester. Secondly, the selective approach adopted by most universities in choosing potential candidates is not in sync with the needs of the large numbers of doctors seen within primary care clinics throughout the country.

The unattractive packages offered by these professional bodies have led to the poor uptake of these courses from untrained medical doctors in the Malaysian public health sector. Consequently, this situation has generated an almost exponential number of untrained GPs in the country. With proper training, GPs are meant to be expert medical generalists capable of handling undifferentiated cases with skilful ability.

Thus without compulsory, convenient and effective training, the current situation does not bode well for the safety of patients and the quality of care from doctors whom they are seeking advice from.

2. Changing the general mindset attributed to traditional conditioning or indoctrination

I personally believe that there should be a major paradigm shift away from the widespread myopic narrative that primary care services should be overlooked or considered any less superior than acute or emergency care rendered by hospitals. Both services are similar to the faces on both sides of the coin - one can never function effectively without the other. Thus, policies should be aimed to achieve smooth and cohesive integration between these two disparate but equally important fields in medicine.

3. Strategic human resource management.

Prior to collaboration between tertiary care and universities, the government should take serious steps to improve relations between the various institutions that are within the immediate purview of the ministry. Malaysia has one of the highest levels of power distance in the world.

Low work motivation among government officers in Malaysia was found to be associated with poor communication between employees and the management separated by high power distance (Mahazril’Aini 2012). Workers also have the propensity to appease superiors to obtain patronage (Ansari, Ahmad, and Aafaqi 2004).

Hence, a more nuanced human resource management is necessary, starting with the abolition of politics of patronage, the recognition of equal partner relationship at all levels and addressing the intrinsic motivation of health care workers (Swarna Nantha, 2016).

I will have to concede that this is not an exhaustive list of problems that require reform. Other equally important areas are worth exploring such as primary care research, experience-oriented career pathways, and appointment based consultations are beyond the scope of this article.

When I teach students during their family medicine rotations, I frequently relay to them an analogy that aptly summarizes the function of primary care and tertiary care services in our country. If we wish to prevent problems from cropping up, we should diligently adhere to vehicle service appointments at the nearest service centre (i.e. primary care service).

However, if we cease to do that in the long run, automobiles will develop certain complications that will require perpetual visits to a mechanic’s workshop (hospital/tertiary care). Although fairly simplistic, much wisdom can be drawn from this analogy which, in reality, has far-reaching consequences.

We need to transcend previous mistakes and cultivate the intention to do so boldly. It is my hope that this humble contribution helps shine some light in the process of protecting the sanctity the medical fraternity and strengthening the quality of care delivered to all deserving patients.


The views expressed here are those of the author/contributor and do not necessarily represent the views of Malaysiakini.

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