KUALA LUMPUR, June 20 — The Health White Paper (HWP) proposes registering all Malaysians with a primary health care provider of their choice close to their home or place of work.
The 59-page document by the Ministry of Health (MOH) – which was passed by the Dewan Rakyat last Thursday – emphasises primary health care (PHC) as the bedrock of a new service model for the country that is more comprehensive and closer to the community.
“The improvement of the national health level for the long term requires a transition to a new service model through the delivery of health care services that are more comprehensive and closer to the community.
“To achieve this goal, PHC will play the role of the first line of defence to monitor and manage the health status of the population. Resources for health for primary care will be improved in terms of allocation, human resources, facilities and equipment to standardise services as needed by the national health system.
“PHC will be the first point of contact that provides a variety of services that is more comprehensive, including promotive, preventative, curative, rehabilitative and palliative care which is people-centric and closer to the community. Each individual will be registered with a PHC service provider of their choice that is close to their home or place of work in stages.”
In terms of service provision, the HWP proposes five reforms in this area: the prioritisation of primary health care delivery, the optimisation of hospital care services, the enhancement of effective public-private cooperation, the leveraging of advancement in digital technology, and ensuring equity of access in health care services.
Under this new model of health care, the HWP advocates for PHC services to be carried out by a multidisciplinary teams of professionals, commonly known as primary care teams, who will be responsible for the population that is registered with their clinic or place of operations.
The HWP said the use of multidisciplinary teams that are rooted in the community will foster long-term doctor-patient relationships and improve the coordination of services across various sectors and levels of care.
And to ensure the realisation of this concept, training and capacity building for PHC care service providers will be carried out, and in addition to that, the HWP proposes that new positions and qualifications be determined and provided to facilitate the transformation of the PHC.
“PHC teams will be responsible to monitor the health status of the population that have registered with their respective clinics or operating area. This will nurture long-term relations between doctor and patient as well as improve the quality and continuity of care as well as patient adherence to treatment.
“Delivery service coordination across various levels and sectors will be improved through the coordination by the PHC, primarily for referrals to specialists or for hospitalisation with the use of electronic medical records (EMR) that will simplify the feedback procedure between each level of care and health facility.”
Central to the coordination across health care sectors and levels are the patient’s EMR and electronic lifetime health records (ELHR). These records are created using an integrated health information system via secured computer networks which are available to authorised care providers. These care providers can use these records for consultation and various other purposes across health care settings.
The use of EMR is nothing new for Malaysia. In 1999, Selayang Hospital was the first tertiary hospital in Malaysia to go fully electronic and paperless with a comprehensive total hospital information system (THIS).
THIS was implemented in the public hospital for all processes: from admission and registration to clerking and prescription writing, ordering medications, laboratory tests, imaging, scheduling, nursing entries, reports, discharges, and transfers.
However, Selayang Hospital’s EMR system has since declined into obsolescence, leading to increased burden on doctors, significant delay in operations, and substandard care.
“With the passage of time and continuous advancements in health care technology, the infrastructure and analytics of the health information system will be upgraded,” said the HWP.
These records will be launched in stages and will contain the individual’s health status, medical history and other pertinent information. This information will be held by the individual who can then choose to give access to their health service providers and government when needed. The fact that the data remains in the hands of the individual keeps it private and confidential, according to the HWP.
With that being said, these records will not only be used as a repository for patient information and history, but will also be used to tailor personal smart health plans for Malaysians. Moreover, analysis of the overall nationwide data will give the MOH a more detailed understanding of diseases and enable a targeted approach to risk assessment, prevention, diagnosis and classification of diseases, clinical investigation and treatment.
In addition to the use of EMR and ELHR, the HWP seeks to strengthen the delivery of primary care services by improving operations which encompasses, amongst other things, the scheduling of appointments, the extension of operational hours and the use of a telehealth system.
When it comes to telehealth, the HWP holds that the system will improve access to health care in hard-to-reach places and populations and allow patients who are stable to have virtual consultations with their doctor, saving both time and money. Furthermore, when combined with other systems, the addition of telehealth will simplify and upgrade the health response system.
This strengthening of primary care will serve to relieve secondary and tertiary health care facilities of some of their burdens.
“The transformational success of the PHC will help lower the health care demands in stages at secondary and tertiary facilities as well as lower the prevalence of sickness through early diagnosis and intervention along with better disease management throughout the individual’s life.”
An Enhanced Primary Health Care (EnPHC) pilot project was implemented in 2017. Then-Health Minister Dr S. Subramaniam said RM26 million was allocated for the first five years of the project spearheaded by the states of Johor and Selangor. The project was set to store the medical records of 300,000 Malaysians at 20 public health clinics (klinik kesihatan) and also see patients assigned to Family Health Teams. Patients under the programme were to be examined by the same doctor every time and the team would conduct a thorough screening to determine the proper intervention.
The HWP proposed improvement of the EnPHC master plan by taking into account the findings of the pilot programme, integrating more relationships across sectors, and monitoring the need for training and upgrading of skills.
Additionally, the paper proposes that the MOH strengthen its supervision and governance to cover the updating and accreditation of performance standards for PHC service providers in public, private, and non-profit facilities and organisations.
To facilitate the provision and coordination of PHC services across sectors, the HWP suggests that a comprehensive framework be founded, which includes a mechanism to ensure the delivery of value-based services and better nationwide coverage.
The paper stipulates that the PHC transformation will start in the public sector and continue in stages and will later include the private sector. Execution of management, operational and financial autonomy will also be carried out in stages for public health care service providers according to feasibility.
Hospital Autonomisation Aimed to Incentivise Performance
Public hospitals are set to become autonomous under the HWP. Taking note of Vietnam and the 2012 World Bank Report on increased services and efficiency and lower costs, the paper proposes that the autonomy granted to hospitals will take place in stages based on a set management framework.
Hospital autonomy, ultimately, is the decentralisation of authority to varying degrees at the health facility level for a variety of financial and managerial decisions. This transforms the hospitals into a more independent entity responsible for their performance.
This means that the structures, incentives and competitiveness of the private sector will be applied to public hospitals with the expectation that market pressures will result in better performance outcomes, and higher efficiency and quality.
This autonomy, based on the HWP, is meant to complement the existing hospital cluster concept present in Malaysia.
The Malaysian Cluster Hospital Initiative (CHI) is a hospital merger exercise to establish an integrated network of specialist and non-specialist hospitals. The hospitals in a cluster would share resources, see a realignment of services offered and have better care coordination, all of which have shown better operational efficiency and quality of care from the provider’s perspective.
“The prestige and efficiency in the public sector will be improved through the hospital autonomy initiative. The level of autonomy will be carried out in stages based on the framework which will be established.
“The autonomy initiative will be aligned with the cluster concept effort where the public hospital sector in the same area will be organised to further increase the efficiency in administration as well as procurement management, human resources and the sharing of other health resources through collaboration between facilities in a cluster.”
Subsequently, the cluster concept will function as a platform to provide clinical services that are more integrated across facilities. This cluster concept will be broadened in stages to include district hospitals and MOH specialist hospitals, as well as other public facilities under the Ministry of Higher Education and the Ministry of Defence.
To further aid in improving care, the HWP proposes that public-private partnerships be expanded at the hospital level in terms of service procurement. This will not only allow for better patient access, but it will also optimise the use of resources at public and private hospital facilities Additionally, the partnership will also improve pre-hospital care services and improve the responsiveness of ambulances.
With that being said, the HWP holds that investment in human capital development to build better management is also needed in public hospitals, and as such, the workforce mapping in hospitals will be thoroughly reviewed and updated to meet current and future needs.
Public hospitals, like health clinics, will also use the EMR and ELHR records to improve efficiency and effectiveness.
Ultimately, based on the reforms, hospitals will be restructured to only focus on acute cases and complex diseases. Ambulatory care-sensitive conditions such as lung and respiratory tract infections, and diarrhoea will be rerouted to PHC facilities, as primary care and community care are better suited to the treatment of those diseases.
Even long-term care, such as care for the elderly or the management of non-communicable diseases (NCDs), will be dealt with outside the hospital through collaboration with other health care providers.
“Long-term care, for example, care for the elderly or management of NCDs with complications, too will be operated outside the hospital facility via collaborations with social care [and] rehabilitative or palliative care services. Management of transitional care, such as post-operative care, will also be managed at the community level to lower hospital readmission after discharge.”
Health Minister Dr Zaliha Mustafa told Parliament last Thursday that granting autonomy to public health care facilities did not entail privatisation, maintaining that such MOH facilities would still be owned by the MOH as not-for-profit organisations.
Private-Public Partnership For Procurement Of Health Services And Medicine
HWP proposes that a strong framework be developed to increase public-private cooperation for the implementation of strategic procurement of health care services and medication from the private sector.
The framework is to lay out an outline of the functions and role of the Strategic Purchaser, which includes value-based payment models and governance and regulations to ensure the people get quality health services.
Along with the framework, the HWP states that sharing the EMR and ELHR at the health care service provider level will strengthen the collaborative relationship between the sectors and allow for better patient movement between the two sectors and a smoother flow of referral feedback.
