PRIMARY CARE SERVICES IMPORTANT
IREFER to the article, “Dzulkefly outlines 6 measures for better health services” (NST, June 10), in which it said the Health Ministry outlined strategies to optimise healthcare services.
The policies called for structural changes in infrastructure to uplift the healthcare delivery system.
Kudos to new Health Minister Dr Dzulkefly Ahmad for solving the problems of patients seeking services at government hospitals.
However, in the true spirit of reform in this country, I beg to differ with the approach adopted by the ministry for two reasons.
FIRSTLY, the approach is too mainstream; and,
SECONDLY, the strategy overlooks the importance of public health and primary care services.
These policies reflect the mainstream response to this type of problem, which continues to be the neglect of the importance of synchrony between primary care and other services.
While I believe that these new policies are not etched in stone, subsequent revisions should reflect dynamism by recognising the importance of preventive medicine in ensuring the health status of the nation.
Evidence from the Starfield Report (Starfield, 2005) has demonstrated that primary care helps to prevent illness and death.
Also, primary care services are associated with equitable distribution of health in the population (Starfield, 2005).
Furthermore, there has been an upsurge in the burden of noncommunicable diseases (NCDs) in the country, contributing to 73 per cent of the deaths in the productive age group (National Health and Morbidity Study, 2015).
These alarming trends have prompted 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 highlight three problems areas that the ministry should focus on:
of primary care doctors the ministry should streamline the oversight of family medicine training under a professional membership body tasked with designing training programmes, supervising general practitioners and ensuring members adhere to a strict set of ethics.
In Malaysia, there is a discrepancy between the modalities designed to produce primary care doctors.
Local universities, with differing curriculum and education standards, offer training for candidates vying for family medicine specialisation.
The number of doctors selected for this pathway remains relatively low given the number of training posts in universities.
Alternatively, the Academy of Family Medicine Malaysia and the Royal College of General Practitioners in Australia have developed a conjoint training programme tweaked to match the standards of programmes at local universities.
Hence, the training of family medicine specialist appears to be under the supervision of two professional bodies with different curriculums with varying levels of exposure to research, workplacebased training and student intake per semester.
The selective approach adopted by most universities in choosing potential candidates is not in synch with the needs of the large number of doctors in primary care clinics.
The unattractive packages offered by these professional bodies have led to the poor uptake of these courses from untrained medical doctors in the public health sector.
Consequently, this situation has generated an almost exponential number of untrained general practitioners (GPs).
With training, GPs are meant to be expert medical generalists capable of handling undifferentiated cases skillfully.
Thus, without compulsory, convenient and effective training, the situation does not bode well for the safety of patients and the quality of care of doctors whom they are seeking advice from.
the mindset attributed to traditional conditioning or indoctrination
I believe that there should be a paradigm shift away from the myopic narrative that primary care services should be overlooked or considered less superior than acute or emergency care rendered by hospitals.
Both services are similar as one can never function without the other.
Thus, policies should achieve a smooth and cohesive integration between these two disparate but equally important fields in medicine.
management
Prior to collaboration between tertiary care and universities (as suggested in the article), the government should improve relations between institutions under the purview of the ministry.
Malaysia has one of the highest levels of power distance in the world (The Asian Leadership Index Report 2014).
Low work motivation among government officers was found to be associated with poor communication between employees and the management separated by high power distance (Mahazril’Aini, 2012).
Workers have a 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 healthcare workers (Swarna Nantha, 2016).
This is not an exhaustive list of problems that require reform. Other areas — 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 relay to them to an analogy that summarises the function of primary care and tertiary care services.
If we wish to prevent problems from cropping up, we should adhere to vehicle service appointments at a service centre, that is, primary care service.
However, if we cease to do that, in the long run, automobiles will develop complications that will require perpetual visits to a mechanic’s workshop (hospital or tertiary care).
Although simplistic, much wisdom can be drawn from this analogy, which, in reality, has farreaching consequences.
We need to transcend mistakes and cultivate the intention to do so boldly.
I hope I have focused attention on protecting the medical fraternity and strengthening the quality of care.