Stethoscope: Integrate primary care into the national immunisation programme

This article first appeared in Forum, The Edge Malaysia Weekly, on June 7, 2021 - June 13, 2021.
Stethoscope: Integrate primary care into the national immunisation programme
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The National Covid-19 Immunisation Programme (NIP) vaccine rollout has highlighted a much-needed revamp of the primary healthcare system in Malaysia, owing mostly to the glaring absence of primary healthcare’s involvement in NIP. In this article, we describe Malaysia’s primary healthcare landscape, explain its importance to the health of Malaysians and propose three ways to better integrate primary healthcare into NIP.

At present, primary healthcare in Malaysia falls into both government clinics comprising nearly 3,000 Klinik Kesihatan (health clinics), Klinik Desa (rural clinics), 1Malaysia clinics, community clinics and the rural health service; and about 8,000 private general practices/clinics, which are mostly clustered in urban and semi-urban areas.

The primary healthcare system provides basic curative services for simple coughs and colds and also long-term care for chronic diseases such as diabetes and hypertension. These 11,000 clinics are also essential for preventive and promotive medicine, including childhood vaccinations, smoking cessation and health screening programmes. Taken together, these curative, preventive and promotive services support a big bulk of medical cases before secondary and tertiary healthcare in hospitals. This reduces the burden on our public hospitals.

Government clinics in Malaysia perform an additional “gatekeeper” service before patients can see government specialists. In this gatekeeper system, the doctor in the government clinic is a steward of government resources by appropriately referring patients to relevant specialists.

This reduces unnecessary referrals and cost, which in turn increases the equity in our health system and reduces waiting times for specialist care. The gatekeeper function is not present in the private system, as patients can go directly to a private specialist (even if they do not need one), and this partly explains why the private healthcare system is much more expensive than public healthcare.

Primary healthcare is important

For the individual, primary healthcare provides familiarity, trusted relationships and a deep understanding of an individual’s unique needs and circumstances. Ideally, all Malaysians should belong to the same primary care doctors.

In other countries, they are called family doctors or family practices. The same doctor (or primary care practice) will deliver womb-to-tomb services, including curative, preventive, promotive and referral services. This provides a one-stop centre for all the health data for one patient, which is important if that patient gets referred to a cardiologist, an endocrinologist, a nephrologist, a dietitian and a physiotherapist in the space of just one week.

Primary healthcare is an effective, fair, affordable and user-friendly way to deliver stronger health outcomes on a systemic level. A hospital-based care system is obviously effective but potentially unfair because no government can build hospitals in every village or town in Malaysia. Hospitals are also very expensive, delivering cutting-edge services that may not be needed by most patients. Hospitals have doctors that come and go, and this leads to unfamiliar (and often disconcerting) situations for patients who may expect more intimate and friendlier settings.

Large volumes of research have shown the importance of primary healthcare in all countries, regardless of their income levels. The success of healthcare systems in rich countries and their gains in life expectancy are due to the success of their primary care system, not their spending on expensive specialist care in hospitals. In other words, rich countries depend on their primary care systems, and not their hospitals, to achieve strong health outcomes.

In my (Dr Hannah’s) experience in working and accessing healthcare in the UK’s National Health Service (NHS), all residents, including non-citizens and students, must register with an NHS primary healthcare clinic — whether or not they wish to access secondary care in the public or private sector.

These primary healthcare clinics are manned by family medicine specialists called general practitioners (GPs) in the UK, who spend two years of foundation training (called a house officer in Malaysia) and three years of specialty training in hospital and primary healthcare settings. They must pass postgraduate exams by the Royal College of General Practitioners before they can call themselves a GP.

In the UK, there are minimum entry requirements to become a GP, rather than GPs being a “default option” in Malaysia for doctors who choose not to specialise in hospital medicine. Therefore, GPs in the UK are equivalent to doctors who specialise in family medicine in Malaysia.

In the Covid-19 vaccination programme, UK residents do not need to register for vaccinations. They simply wait to be called for vaccinations by their specific primary care doctors via post, email or telephone. They are called for vaccinations according to their risk levels, age group and comorbidities.

Those who are shielding (meaning they are staying at home to avoid risk) and housebound patients can be accounted for and can receive their vaccinations at home. By using the general practitioner network, there is more inclusivity, no preferential treatment, an ability to anticipate refusals and an ability to easily call the next person in the priority list for vaccinations.

Three ways to integrate primary healthcare into NIP

Given the reach, familiarity and importance of primary healthcare, we propose three ways to integrate primary healthcare into NIP. The objectives are to maximise the existing strengths of primary healthcare in Malaysia, speed up the implementation of NIP and reach herd immunity faster.

First, primary healthcare can be used to register citizens for vaccines. The low registration for voluntary vaccination (currently around 45% registration after four months) among Malaysia’s 9.4 million senior citizens is not unexpected. Not many senior citizens or those in rural areas have access to the internet or are tech-savvy. This is especially true for senior citizens or rural folk from disadvantaged backgrounds. Primary care clinics (both public and private) in Malaysia can be a tool to increase vaccine registration. MySejahtera should add the functionality to allow primary care clinics to register their patients, or private clinics can be given a quota for registration.

Second, primary healthcare can be used to deliver vaccines. So far, only about 2,500 private general practitioners have registered to deliver vaccines in a programme administered by ProtectHealth (a company fully-owned by the Health Ministry). Of the 2,500 registered private GPs, it is unclear how many are actually delivering vaccinations in the first four months of the NIP (ProtectHealth does not routinely announce this number). Whatever the number, it is a small fraction of the 8,000 private GPs, and more should be added, especially as more vaccine supplies begin arriving. The infrastructure and cold chain for vaccines may need to be strengthened in certain areas, but this will help other vaccination programmes that are led by private GPs (such as hepatitis, HPV and childhood vaccines).

Third, primary healthcare can be used to increase vaccine confidence. Vaccine misinformation, which is rife on social media and WhatsApp groups, also contributed to the low registrations of voluntary vaccination, especially after the AstraZeneca vaccine blood clot scare. Given the trusting, familiar and intimate therapeutic relationships between GPs and their patients, GPs can be a reliable and reassuring source of information for vaccines. This requires the NIP to actively train GPs on the science and persuasion skills needed to communicate on vaccines.

These three integrating steps are merely the first steps towards a stronger primary healthcare system in Malaysia. We advocate for a comprehensive long-term reform of Malaysia’s primary healthcare system. This should include additional relevant training for GPs (including appropriate additional diplomas and certificates), the involvement of family medicine specialists, as well as a revision of the fee schedule to recognise and reward those with additional qualifications and skills.

Portable electronic health records for Malaysians should be created, and these health records should allow for seamless care transitions between primary-secondary-tertiary care and between the public-private sectors. Strengthening primary care in Malaysia will help the NIP in particular, but also health in general (for example, through screening programmes or management of chronic diseases).

Meanwhile, there remains much that primary healthcare can offer NIP. The quicker we integrate primary care practitioners into NIP, the faster our exit strategy from this pandemic.

Dr Hannah Nazri is a medical doctor and a DPhil scholar at the University of Oxford. Dr Khor Swee Kheng is a physician specialising in health policies and global health.

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