NHEWS PRIMARY CARE 2012 FullReport
MINISTRY OF HEALTH MALAYSIA
NCRC/HSU/2013.2
EDITED BY:
HWONG WY, SIVASAMPU S,
AISYAH A, SHANTHA KUMAR C,
GOH PP, HISHAM AN
NATIONAL HEALTHCARE
E S TA B L I S H M E N T &
WORKFORCE STATISTICS
PRIMARY CARE
2012
N AT I O N A L H E A LT H C A R E S TAT I S T I C S I N I T I AT I V E
National Healthcare Establishment and Workforce Statistics (Primary Care) 2012
March 2014
© Ministry of Health Malaysia
Published by:
The National Healthcare Statistics Initiative (NHSI)
National Clinical Research Centre
National Institutes of Health
3rd Floor, MMA House
124, Jalan Pahang
53000 Kuala Lumpur
Malaysia
Tel.
:
(603) 40439300
Fax
:
(603) 40439400
e-mail
:
hsu@crc.gov.my
Website :
http://www.crc.gov.my/nhsi
This report is copyrighted. Reproduction and dissemination of its contents in part or in whole for research, educational or
non-commercial purposes is authorised without any prior written permission provided the source is fully acknowledged.
Suggested citation:
Hwong WY, Sivasampu S, Aisyah A, Shantha Kumar C, Goh PP, Hisham AN. National Clinical Research Centre.
National Healthcare Establishment & Workforce Statistics (Primary Care) 2012.
Kuala Lumpur 2014.
This report is also available electronically on the website of the National Healthcare Statistics Initiative at:
http://www.crc.gov.my/nhsi/
Funding:
The National Healthcare Statistics Initiative was funded by a grant from the Ministry of Health Malaysia
(MRG Grant No. NMRR-09-842-4718)
Please note that there is potential for minor corrections of data in this report. Please check the online version at
www.crc.gov.my for any amendments
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
TABLE OF CONTENTS
ACKNOWLEDGEMENTS
iii
PROJECT TEAM
iv
ABBREVIATIONS AND SYMBOLS
v
INTRODUCTION
Background
vi
vi
Objectives
vi
METHODOLOGY
Sampling Frame and Sample Size Calculation
Data Collection and Follow-Up
Data Entry
Data Cleaning and Veriication
Statistical Analysis
Ethical Issues
Limitations
Consort Diagrams
RESPONSE RATE
vii
vii
viii
ix
ix
ix
ix
x
xi
xiii
CHAPTER 1 | OVERVIEW
1
CHAPTER 2 | PRIMARY HEALTHCARE ESTABLISHMENTS
3
4
4
5
8
Types of Private Practice
Attendances
Electronic Healthcare Computer System
Tables for Figures
CHAPTER 3 | PRIMARY HEALTHCARE FACILITIES
Tables for Figures
11
13
CHAPTER 4 | PRIMARY HEALTHCARE SERVICES
15
15
16
16
17
20
Types of Services
Antenatal Care
Laboratory Services
Operating Days and Operating Hours
Tables for Figures
CHAPTER 5 | PRIMARY HEALTHCARE WORKFORCE
Characteristics of Healthcare Providers: Age, Gender and Years of Experience
Working Hours and Full-Time Equivalence
Family Medicine Specialists
Other Healthcare Professionals
Tables for Figures
CHAPTER 6 | PRIMARY HEALTHCARE MEDICAL DEVICES
Tables for Figures
23
23
25
26
27
29
31
35
APPENDICES
APPENDIX 1 | ADDITIONAL TABLES
37
APPENDIX 2 | PARTICIPANTS OF NHEWS PRIMARY CARE 2012
39
APPENDIX 3 | LIST OF DEFINITIONS
43
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LIST OF TABLES
Table 2.1.
Percent of Clinics with Electronic Healthcare Computer System in 2012
5
Table 2.2.
Number of Malaysian Primary Care Clinics per 10,000 Population in 2011
8
Table 2.3.
Types of Private Practice by State/Region in 2012
8
Table 2.4.
Median Attendances per Clinic per Day by State/Region and Sector in 2011
8
Table 2.5.
Percent of Fully Computerised Clinics by Sector in 2012
9
Table 2.6.
Types of Computer Usage by Sector in 2012
9
Table 3.1.
Types of Facilities by State/Region and Sector in 2012
11
Table 3.2.
Distribution of Functioning Ambulances in Public Clinics by State/Region in 2012
12
Table 3.3.
Percent of Public Clinics with Laboratory Space and Ambulance Services by State/Region in 2012
13
Table 4.1.
Percent of Clinics providing Antenatal Services by State/Region and Sector in 2012
16
Table 4.2.
Types of Services Available by Sector in 2012
20
Table 4.3.
Types of Laboratory Services by State/Region and Sector in 2012
20
Table 4.4.
Number of Operating Days per Week in Private Clinics by State/Region in 2012
20
Table 4.5.
Number of Operating Hours per Day in Private Clinics by State/Region in 2012
21
Table 4.6.
Types of Operating Hours per Day in Public Clinics by State/Region in 2012
21
Table 5.1.
Distribution of Medical Doctors by State/Region and Sector in 2012
23
Table 5.2.
Types of Post-Graduate Qualiications for Family Medicine Specialists by Sector in 2012
27
Table 5.3.
Distribution of Other Healthcare Professionals by State/Region and Sector in 2012
28
Table 5.4.
Age Distribution of Medical Doctors by State/Region and Sector in 2012
29
Table 5.5.
Years of Experience of Medical Doctors by State/Region and Sector in 2012
29
Table 5.6.
Gender Distribution of Medical Doctors by Sector In 2012
29
Table 5.7.
Median Working Hours per Week per Doctor by State/Region and Sector In 2012
30
Table 5.8.
Number of Patients Seen per Day per FTE Private Clinic Doctor by State/Region in 2012
30
Table 5.9.
Distribution of Family Medicine Specialists by State/Region and Sector in 2012
30
Table 6.1.
Distribution of Functioning Medical Devices per Clinic by State/ Region and Sector in 2012
Table 6.2.
Percent of Clinics with Functioning Medical Devices by Sector in 2012
35
Table A1.1.
Median Number of Attendances per clinic per year by State/Region and Sector in 2011
37
Table A1.2.
Median Number of Attendances (Outpatient, Home Visit, Antenatal Visit) per clinic per year by
State/Region and Sector in 2011
37
Table A1.3.
Types of Computer Usage by State/Region and Sector in 2012
37
Table A1.4.
Types of Services Available by State/Region and Sector in 2012
38
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ACKNOWLEDGEMENTS
The National Healthcare Statistics Initiative Primary Care team would like to thank the Director General of Health
Malaysia for his continuous support towards this survey and the permission to publish this report.
We would also like to express our sincere appreciation to the following for their participation, assistance, support and
contribution:
● Deputy Director General of Health (Research and Technical Support), MOH
●
Deputy Director General of Health (Public Health), MOH
●
Deputy Director General of Health (Medical), MOH
●
Director, National Clinical Research Centre (NCRC), National Institutes of Health (NIH)
●
Director, Family Health Development Division, MOH
●
Director, Medical Practice Division, MOH
●
State level Private Medical Practice Control Units (Unit Kawalan Amalan Perubatan Swasta, UKAPS) of Kelantan, Sabah,
Sarawak, Selangor and Wilayah Persekutuan Kuala Lumpur.
●
Malaysian Medical Council, Malaysian Medical Association, Academy of Family Physicians Malaysia, National
Specialist Register
Our special thanks and gratitude also goes to
●
All medical doctors and support personnel from the participating public and private clinics whom have kindly provided
data on their respective establishment and workforce
●
The team from Family Health Development Division, MOH whom have generously shared data on public primary
care establishment and workforce
And all those who have supported or contributed to the success of the NHEWS Primary Care Survey 2012 and the
publication of this report
Thank you.
National Healthcare Statistics Initiative (NHSI) Primary Care Team
Healthcare Statistics Unit
National Clinical Research Centre (NCRC)
Ministry of Health, Malaysia
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PROJECT TEAM
Principal Investigator
Datuk Dr. Noor Hisham Abdullah
Dr Sheamini Sivasampu
Principal Co-Investigators
Dr. Goh Pik Pin
Dr Kamaliah Mohd. Noh
Dr. Kaviyarasan Sailin
Professor Dr. Khoo Ee Ming
Research Evaluation Committee
Associate Professor Dr. Ng Chirk Jenn
Professor Dr. Tauik Teng Cheong Lieng
Associate Professor Dr. Jamaluddin Abdul Rahman
Project Manager
Dr. Hwong Wen Yea, Amy
Survey Coordinator
Ms. Aisyah Ali
Research Oficers
Ms. Sharmini Chandran
Ms. Hanan Hamimi Wahid
Dr. Hwong Wen Yea, Amy
Data Analysts
Ms. Norazida Ab Rahman
Mr. Shanthakumar Chandrasekaran
Database Developer/Administrator
Altus Solutions Sdn. Bhd.
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
ABBREVIATIONS AND SYMBOLS
CKAPS
Cawangan Kawalan Amalan Perubatan Swasta
CI
Conidence Interval
CRF
Case Report Form
df
Degree of Freedom
DG
Director General of Health, Ministry of Health Malaysia
e-CRF
Electronic Case Report Form
FAFP
Florida Academy of Family Physician
FMS
Family Medicine Specialist
FRACGP
FRCGP
Fellowship of the Royal Australian College of General Practitioners
Fellowship of Royal College of General Practitioners
FTE
Full Time Equivalence
GP
General Practitioner
IQR
Interquartile Range
KK
Klinik Kesihatan
MOH
MRCGP
MREC
NA
NCRC
NHEWS
NHSI
Ministry of Health
Member of Royal College of General Practitioners
Medical Research Ethics Committee
Not Available
National Clinical Research Centre
National Healthcare Establishment and Workforce Survey
National Healthcare Statistics Initiative
NIH
National Institutes of Health
NMCS
National Medical Care Survey
No.
Number
SD
Standard Deviation
UKAPS
WHO
WP
-
Unit Kawalan Amalan Perubatan Swasta
World Health Organisation
Wilayah Persekutuan
Not Applicable
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INTRODUCTION
Background
The National Healthcare Statistics Initiative (NHSI) is a family of surveys looking into services, healthcare workforce,
processes of care as well as some medical technologies of our dual healthcare system.This initiative is part of the Ministry
of Health Malaysia’s (MOH) move towards the availability of better health statistics. Healthcare statistics is a key element
of any country’s policymaking, monitoring and evaluation system. NHSI was initiated in 2009 by the National Clinical
Research Centre (NCRC) in collaboration with relevant MOH and private sector stakeholders. The Healthcare Statistics
Unit (HSU) in NCRC is the program coordinator of this initiative. Over the past 4 years, the NHSI has managed to
gain recognition as a reliable source of healthcare statistics providing useful and timely data which ills the gap between
research and policy.
It is well established that primary care services act as the gatekeeper of any healthcare system. The development of both
National Healthcare Establishment and Workforce Primary Care Survey (NHEWS) and National Medical Care Survey
(NMCS) was mooted when it was realised that there was very little known at large about the primary care system in
Malaysia; especially on the resources and contribution of the private primary care clinics and their providers. Being one
of the four surveys in NHSI, the NHEWS Primary Care Survey is in its third year of inception with two prior surveys
conducted in 2009 and 2010 respectively. In 2012, the project team had decided to pilot test the revised version of NMCS;
hence downsizing NHEWS Primary Care 2012 in terms of national representation.
Objectives
General Objectives
NHEWS Primary Care aims to:
1. determine the availability and distribution of primary healthcare services, facilities and healthcare workforce
2. compare the services, facilities and workforce in primary care between the public and private
3. monitor the trends of the services, facilities and workforce in primary care
4. provide reliable data for the purpose of healthcare planning, policy making and healthcare expenditure
Speciic Objectives
NHEWS 2012 collects primary care data on:
1.
the total number and density of primary care clinics at national level by states and sector
2.
the availability and distribution of primary care facilities and services in the chosen states (Selangor & Wilayah
Persekutuan (WP) Putrajaya,WP Kuala Lumpur and Kelantan) and regions (Kota Kinabalu and Kuching) by sector
3.
the socio-demographics and characteristics of medical doctors and allied healthcare personnel in the chosen
states (Selangor & WP Putrajaya, WP Kuala Lumpur and Kelantan) and regions (Kota Kinabalu and Kuching) by
sector
4.
the distribution of selected medical devices in the chosen states (Selangor & WP Putrajaya,WP Kuala Lumpur and
Kelantan) and regions (Kota Kinabalu and Kuching) by sector
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METHODOLOGY
General
NHEWS 2012 was a cross-sectional study. Random sampling was performed on the primary care clinics in 5 selected
regions which include:
• Kelantan to relect East Coast of Peninsular Malaysia
•
WP Kuala Lumpur, WP Putrajaya and Selangor to relect West Coast of Peninsular Malaysia
•
Kuching and Kota Kinabalu to relect East Malaysia
Approval for NHEWS Primary Care protocol was granted by MOH Medical Research and Ethics Committee (MREC) in 2010.
Sampling Frame and Sample Size Calculation
The determination of total population for the survey was inalised prior to the initiation of data collection. This involved
record matching of clinics from the NHEWS Primary Care 2010 list against independent databases from Ministry of Health’s
Private Medical Practice Control Section (CKAPS) and Family Health Development Division. Checking of duplicates and
matching were done by the Information Technology (IT) department. Both matched and unmatched records were then
reviewed by NHEWS Primary Care team and subsequent veriication was conducted by contacting each site to conirm
their operational status. The review and veriication processes were repeated and closed clinics were removed from the
sampling frame.
The inclusion and exclusion criteria for the survey were as stated below:
INCLUSION
CRITERIA
EXCLUSION
CRITERIA
•
All private medical clinics registered with the Medical Practice Control Section or Cawangan
Kawalan Amalan Perubatan Swasta (CKAPS) providing primary care (up to 31st December 2011)
•
All MOH Health Clinics (Klinik Kesihatan) delivering outpatient services by medical doctors. (up to
31st December 2011)
•
Government clinics which fell into the categories of:
- Outpatient departments within public hospitals
- Klinik Kesihatan without medical doctors
- Clinics providing maternal and child health services only (Klinik Kesihatan Ibu dan Anak)
- Rural Clinics (Klinik Desa)
- 1 Malaysia Clinics
- Primary care clinics in universities
•
Private Clinics which fell into the categories of:
• In-house clinics /company clinics
• Clinics providing specialised care/ Specialist clinics e.g. paediatric, cardiology, occupational therapy
• Diagnostic centres
• Aesthetic clinics
• Charity clinics
The random sampling method used for sample size calculation was a complex multistage stratiied random sampling.
Stages for the sampling involved:
Stage 1: Selection of Sampling Regions (Convenience / Purposive Sampling)
• WP Kuala Lumpur, Selangor and WP Putrajaya, Kelantan, Kuching and Kota Kinabalu
Stage 2: Stratiication by Sector
• Each region was stratiied to both public and private sector.
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Stage 3: Sampling of Clinics
• Random sampling was done based on random numbers generated from Microsoft Excel. During the sampling, the
inclusion and exclusion criteria for both public and private sectors were accounted for.
The table below shows the inal calculated sample size:
Sample Size for NHEWS Primary Care 2012
State/Region
No. of clinics
Public
Private
Selangor & WP Putrajaya
39
187
WP Kuala Lumpur
8
107
Kelantan
20
57
Kuching
4
21
Kota Kinabalu
4
11
75
383
Total
Data Collection and Follow-Up
These sampled clinics were sent an oficial invitation letter to attend a brieing. Brieings for government doctors were held on
weekdays whereas for private doctors, brieings were conducted on the weekends between June and July 2012.
During the brieings, doctors who attended were given a research pack which contained:
•
Call letter for participation of the survey signed by State Director of Health
•
Case report form (CRF)
•
Username and password for the option of completing the survey form online
•
Prepaid envelope
•
NHEWS Primary Care 2008-2009 report
Clinics which did not send any representatives for the brieings were contacted by phone in an attempt to persuade them
to participate. Many strategies were carried out to increase the response rate of the sampled private clinics.
These included:
• Establishing buy in from senior management of the chain clinics
•
Close cooperation with the state Malaysian Medical Association (MMA) to encourage their members to participate
•
Conducting private brieings to the doctor/nurse-in-charge of primary care clinics around KL/Selangor region
•
Establishing a close rapport with medical enforcements’ oficers of the respective states and regions. At times, the
project team followed the enforcement oficers during their scheduled visits and conducted a private brieing to the
sampled clinics.
•
Contacting clinics via phone. If the doctor agreed to participate, a research pack was sent by express post. This was
followed by a telephone call to conirm that the research pack had been received and a brieing over the phone was
then conducted.
Respondents to this survey had 2 options for modes of data submission which were:
• Paper data submission via hardcopy of the Case Report Form (CRF)
• Electronic data submission via web application (eCRF)
For clinics which failed to return their forms, they were reminded via phone calls. Such reminders were made for both
surveys (NMCS 2012 and NHEWS Primary Care 2012) simultaneously in two stages, ie at 3 weeks and at 5 weeks
after their respective survey dates for NMCS 2012. All participants were encouraged to contact the research team with
questions, at any time during ofice hours by phone.
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Once the survey forms were received either by postage or online, two certiicates and a copy of the NMCS 2010 report
were sent to the participants as a token of appreciation.
Data Entry
Data received via paper submission were thoroughly reviewed for completeness and consistency prior to data entry
into the NHEWS Primary Care database. Data entry was then performed by trained NHEWS Primary Care members.
Data entry from participant’s site through eCRF was submitted directly into the NHEWS Primary Care database and
monitored in real-time basis by the members of the team. Quality of data entry was constantly checked and maintained
by several built-in features in the data entry module such as a compulsory data checking function, inconsistency checks,
auto calculations and auto default data from previous year’s survey. Every activity in the database was recorded in a realtime tracking system.
Data Cleaning and Veriication
Data cleaning was performed in parallel with data entry based on the results of edit checks. An edit check is a data
checking procedure for tracing doubtful data being entered and was performed by NHEWS Primary Care team members
who are familiar with primary care settings. A built in data query feature was also created in the web application to cross
check data from the same variables in 2010 and 2012. Queries that arose were then attended to by contacting the stated
person-in-charge in the form or other authorised representatives to seek further clariication.
All queries were resolved before the database was locked to maintain data quality and integrity. A inal checking was
performed prior to database locking to ensure that the data was acceptable for statistical analysis. The dataset was
then standardised by performing data deduplication procedure for removing duplicate records and checking of range
and consistency to detect outliers. A protocol with validation rules for cleaning as well as data inconsistency rules have
been created for data cleaning. Cross-checking with other relevant data sources such as the Malaysian Medical Council
database, National Specialist Register of Malaysia and list of registered family medicine specialists from the Academy of
Family Physician Malaysia was performed. Most of the missing or out-of-range mandatory variables and auxiliary variables
were resolved during data cleaning stage.
Statistical Analysis
Findings of the survey were primarily reported as descriptive statistics. Statistical analyses were conducted using the
IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp). Categorical data were reported in rates and
proportions but their respective conidence intervals were not reported as the requirements for inferential statistics
were not met.1 Proportions may not always add up to exactly 100.0% due to rounding of igures. Continuous data were
reported in median and interquartile range (IQR). An analysis to determine if there were any signiicant differences
between the characteristics of the respondents and non-respondents from the private general practitioners (GPs) namely
age, gender and years of practice was also conducted. Categorical variables were compared using the χ2-test whereas for
continuous variables; a simple logistic regression.
Ethical Issues
As mentioned above, the survey received ethics approval from Medical Research and Ethics Committee (MREC) of the
MOH. As participation in this study was on voluntary-basis, respondents had the right to decline to participate at any
point of time throughout the study.
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Limitations
1. Only 3 states (Selangor and WP Putrajaya,WP Kuala Lumpur and Kelantan) and 2 regions (Kota Kinabalu and Kuching)
were selected in the survey. The results of this study do not relect national or state representation for Sabah and
Sarawak.
2. The same sample size calculation was used for both NHEWS Primary Care 2012 and NMCS 2012. Further details of
the calculation can be found in the NMCS 2012 report2.
3. The sample was not calculated to represent each type of (Type I to Type VI) clinics in the public sector.
4. The survey was rolled out in July 2012 and hence, data on the number of clinics and total attendances could only be
reported as of the year 2011 as those variables were collected yearly. The rest of the variables were reported as of
30th of June 2012.
5. The results could not be inferred to the population because to our best knowledge, there was a lack of a reliable
national representation of both health sectors for the purpose of applying survey weights.
References
1.
Naing L. Inferential Statistics. Power point presentation. Research Methodology and Basic Biostatistics Workshop, Kuala Lumpur. 23rd-25th
August 2013.
2.
Sivasampu S, Yvonne Lim, Hwong WY, Norazida AR, Goh PP, Hisham AN. National Clinical Research Centre. National Medical Care
Statistics 2012. (unpublished report)
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CONSORT DIAGRAM: PUBLIC PRIMARY CARE CLINICS 2012 (KLINIK KESIHATAN)
Excluded
*Kuching and Kota Kinabalu regions were taken to represent Sarawak and Sabah respectively
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
CONSORT DIAGRAM: PRIVATE PRIMARY CARE CLINICS 2012
*Kuching and Kota Kinabalu regions were taken to represent Sarawak and Sabah respectively
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RESPONSE RATE
The table below shows the response rate for NHEWS Primary Care 2012 Survey:
Response Rate for NHEWS Primary Care 2012 Survey
State/Region
Sector
Sample size
No. of respondents
Response rate (%)
Selangor & WP Putrajaya
Public
39
34
87.2
Private
187
52
27.8
WP Kuala Lumpur
Kelantan
Kota Kinabalu
Kuching
Overall
Public
8
8
100.0
Private
107
30
28.0
Public
20
18
90.0
Private
57
25
43.9
Public
4
4
100.0
Private
21
9
42.9
Public
4
4
100.0
Private
11
4
36.4
Public
75
68
90.7
Private
383
120
31.3
The low response rate from private clinics had already been anticipated and accounted for. A few studies which previously
surveyed private clinics in Malaysia had also reported similar response rates ranging from 26.3% to 33.0%.1,2 Low response
rates in national surveys when physicians were the responders had been associated with many factors such as apathy, lack
of incentives and resistant to healthcare surveys especially those conducted by the government.3,4
In view of this, the sampling matrix calculation had included an estimation of a 30.0% drop-out rate from the public and a
70.0% drop-out rate from the private sector.
A subsequent analysis comparing the respondents and non-respondents from private clinics was performed to ensure
that the low response rate has not introduced any form of bias into the indings. As seen from the tables below, no
signiicant differences in terms of age, gender and years of practice between these two GP groups were observed.
Comparison of age between the respondents and non-respondents in the private sector
Characteristics
Odds ratio
95% CI for
odds ratio
χ2 statistics (df)
P value
1.01
(0.99, 1.03)
0.27 (1)
0.604
Age
*10 missing variables for non respondents
Comparison of gender between the respondents and non-respondents in the private sector
Characteristics
n
Respondents
n (%)
Non respondents
n (%)
χ2 statistic (df)
P value
0.04(1)
0.837
Gender
Male
239
76 (31.8)
163 (68.2)
Female
134
44 (32.8)
90 (67.2)
*10 missing variables for non respondents
Comparison of years of practice between the respondents and non-respondents in the private sector
Characteristics
Odds ratio
95% CI for
Odds ratio
Years of Practice
1.00
(0.98, 1.03)
χ2 statistics (df)
0.15 (1)
P value
0.699
*4 missing variables for respondents and 14 missing variables for non respondents
Having this analysis also increased the validity of the study. As the non-respondents were mainly from the private sector,
the team has kept the comparison between the two groups to private sector only.
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References
1.
Teng CL,Tong SF, Khoo EM, Lee V, Zailinawati AH, Mimi O, Chen WS, Nordin S.Antibiotics for URTI and UTI – prescribing in Malaysian
primary care settings. Aust Fam Physician. 2011; 40(5):325-9.
2.
Mimi O,Tong SF, Nordin S,Teng CL, Khoo EM, Abdul-Rahman A, Zailinawati AH, Chen WS, Shihabudin WM, Noridah MS, Fauziah ZE. A
comparison of morbidity patterns in public and private primary care clinics in Malaysia. Malaysian Family Physician. 2011; 6(1):19-25
3.
Parsons J, Warnecke R, Czaja R, Barnsley J, Kaluzny A. Factors associated with response rates in a national survey of primary care
physicians. Eval Rev. 1994; 18: 756-66.
4.
Cartwright, A. Professionals as responders: variations in and effects of response rates to questionnaires. BMJ. 1978; 2: 1419-21
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
CHAPTER 1
PRIMARY CARE
| OVERVIEW
Primary care provides essential functions for individual patients, health systems and populations. Apart from managing
and triaging undifferentiated symptoms and delivering treatment for acute and chronic illnesses, primary care providers
also manage many different services which include health promotion, disease prevention, health maintenance, counselling,
patient education and many more.1
The Malaysian primary care is of no exception.The two tiered healthcare system i.e. public and private holds an extremely
important position in the delivery of primary care services in Malaysia. This chapter summarises the key indings of
NHEWS Primary Care Survey 2012 by chapters:
Chapter 2: Primary Healthcare Establishments
• There were 5,198 private clinics and 871 public clinics in Malaysia as of 31st December 2011.
•
Overall, there were 2.1 clinics per 10,000 population in Malaysia.
•
75.0% of the private clinics were solo practices.
•
On average, public clinics had a higher total attendances per day compared to the private.The highest ratio was 12:1 (public
versus private).
•
Only 29.3% of the primary care clinics were fully computerised with the majority coming from private sector.
Chapter 3: Primary Healthcare Facilities
•
55 out of 68 public clinics sampled had a triage system implemented in their clinics.
•
None of the private clinics sampled in East Malaysia had a diagnostic imaging/X-ray room in their premises.
•
All public clinics with an exception of WP Kuala Lumpur (62.5%) had a designated laboratory space.
•
The median for functioning ambulances per public clinic in the states/regions sampled is 1.0 (IQR 0.0).
Chapter 4: Primary Healthcare Services
• Only 16.7% of the private clinics offered smoking cessation programmes as compared to 75.0% in the public.
•
More than 90.0% of public clinics provided preventive and health promotion services such as obstetric and
gynaecological services, family planning services and clinical breast examinations. On the other hand, private clinics
performed more minor surgeries (91.7%) and medical check-ups (98.3%).
•
All states and regions sampled had a higher percentage (range: 51.9% - 75.0%) of clinics opening 7 days in a week
except for WP Kuala Lumpur where 73.3% of the clinics had less than 7 operating days in a week.
•
Only 5.0% of the private clinics in the states/regions sampled were functioning as 24-hour clinics.
Chapter 5: Primary Healthcare Workforce
• The median number of doctors per public clinic was 4.5 doctors (IQR 5.0) and 1.0 doctor (IQR 1.0) per private clinic.
•
The majority of doctors (61.1%) practising in the public clinics were between the ages of 25-34 years old. By
comparison, 72.1% of the private clinics’ doctors were ≥ 45 years old.
•
75.5% of the doctors in the private sector had more than 10 years of experience in primary care.
•
Overall, two-third of the doctors in primary care were females.
•
Medical doctors from private clinics worked a median of 47.5 (IQR 21.0) hours per week while public clinic doctors
had shorter working hours per week with a median of 40.0 (IQR 5.0) hours.
•
Kuching region recorded the highest number of patients seen per day per full time equivalence (FTE) doctor (44 patients).
•
Overall, there was a ratio of 1 Family Medicine Specialist to 5 primary care clinics.
1
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
Chapter 6: Primary Healthcare Medical Devices
• Only 51.5% of the public clinics had functioning deibrillators in their premises.
•
Less than 15.0% of the private clinics had laboratory equipments such as bilirubinometer or full blood count analysers.
•
Public clinics had a median of four or more functioning peak low meters per clinic for every state/region while the
private sector had only a median of one functioning peak low meter per clinic.
•
71 out of 73 resuscitation trolleys were functioning in the public clinics. Clinics in both public and private sectors
had at least one resuscitation trolley per clinic except for private clinics in Kelantan which only had a median of 0.6
(IQR 1.0) resuscitation trolley per clinic.
•
About 5.0% of the glucometers in the public clinics were reported to be non-functioning.
Although the survey was restricted to only 3 states and 2 regions sampled, the indings have provided a better understanding
of the primary care services as well as the socio-demographic characteristics of the primary healthcare workforce. These
results, together with the indings of morbidity pattern and processes of care from the National Medical Care Survey
(NMCS) 2012 are hoped to form a clearer picture on the current primary healthcare system in Malaysia.
References
1.
Primary Care. American Academy of Family Physicians, 2013. [Viewed 17th October 2013]. Available from: http://www.aafp.org/about/
policies/all/primary-care.html.
2
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
CHAPTER 2
PRIMARY CARE
| PRIMARY HEALTHCARE ESTABLISHMENTS
Primary healthcare is the foundation of a comprehensive healthcare system for the nation. Its framework is detailed in
the 1978 Declaration of Alma-Ata.This includes at least the following 8 areas: identifying, controlling and preventing health
conditions through education, adequate nutrition, maternal and child healthcare, immunisation against major infectious
diseases, family planning, prevention and control of local endemic conditions, management of common ailments and
injuries and provision of essential drugs.1 Primary care serves as the irst-contact point and as a gatekeeper to secondary
and tertiary health care.2 This highlights the importance of collecting information on the present workforce and health
services in primary care for evaluation of the current system as well as in drafting and implementation of future health
policies.
The two-tiered healthcare system for primary care in Malaysia; the public and private sectors have provided accessibility
to Malaysians for many years. While the public health system is heavily subsidised by the government, the private clinics
charge fee-for-service. As of 31st December 2011, there were 5,198 private primary care clinics and 871 public primary
care clinics in Malaysia. The ratio of private clinics to public clinics was 6:1. This difference has not changed much from the
6.3:1 ratio reported in 2008-2009.3
In summary there were 2.1 clinics per 10,000 population in Malaysia in 2011 (Figure 2.1). Figure 2.1 also shows a consistently
higher number of clinics per 10,000 population in the urban states of which WP Kuala Lumpur had the highest density; 3.7
clinics per 10,000 population.This density however is still low compared to Australia which recorded an average of 6.1 GP
practices per 10,000 population in 2002.4
Figure 2.1. Number of Malaysian Primary Care Clinics per 10,000 Population in 2011
3
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
Types of Private Practice
The majority of practices (75.0%) in 2012 were still individual practices. However, there has been an increase in private
group practices in all states sampled over the two year period.5 Clinics in WP Kuala Lumpur recorded the highest
proportion of group practice at 33.3%. A study in 2003 on physician workforce in Canada reported that the trend
of having group practice was more popular among the younger generation of the general practitioners with the aim
to achieve a more balanced lifestyle in terms of workload distribution.6 The changing trend towards group practice is
also hoped to reduce medical error and negligence in primary care when GPs with different skills and knowledge are
brought together for a more comprehensive diagnosis and treatment of patients. Moreover economics wise, forming
group practices would allow better equipments and facilities to be built and shared.7
Figure 2.2.Types of Private Practice by State/Region in 2012
Attendances
Despite being outnumbered in terms of quantity of clinics, the public sector is seeing the bulk of primary care patients
compared to the private clinics. Our results showed that overall, public clinics had higher attendances compared to clinics
in the private sector (Appendix 1 Table A1.1).The difference was obvious in Kota Kinabalu where the number of attendees
to the public clinics per day was approximately 12 times more than that of the private clinics (Figure 2.3).The public clinics
in Kuching region recorded the highest number of attendees in a day with a median of 463.7(IQR 699.3) attendances per
clinic per day.
The breakdown by types of attendances such as antenatal and home visits can be found in the Appendix 1 Table A1.2.
4
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
Figure 2.3. Median Attendances per Clinic per Day by State/Region and Sector in 2011
Electronic Health Care Computer System
Implementation of a computer system and incorporating information technology in healthcare practices is expected
to play a vital role in the near future especially to acquire, manage and disseminate knowledge and information.8
Among the beneits of using electronic patient record include more eficient transferability of the records, systematic
record keeping where all results and patient notes are kept together, increasing safety of the records and most
importantly, enabling involved GP practitioners to have immediate access to full records.9 Our indings indicate that
more than half (52.7%) of the respondents were already using computers in their establishments (Table 2.1). Out of
these, only 29.3% of these clinics were fully computerised (patient records, dispensing, billing and registration); most
of them from the private sector (Figure 2.4).
Table 2.1. Percent of Clinics with Electronic Healthcare Computer System in 2012
Clinics with computer system
State/Region
Sector
No. of clinics
Selangor & WP Putrajaya
Public
34
WP Kuala Lumpur
Kelantan
Kota Kinabalu
Kuching
Overall
No.
Percent (%)
9
26.5
Private
52
41
78.8
Total
86
50
58.1
Public
8
4
50.0
Private
30
20
66.7
Total
38
24
63.2
Public
18
2
11.1
Private
25
12
48.0
Total
43
14
32.6
Public
4
0
0.0
Private
9
6
66.7
46.2
Total
13
6
Public
4
2
50.0
Private
4
3
75.0
Total
8
5
62.5
Public
68
17
25.0
Private
120
82
68.3
Total
188
99
52.7
5
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
Figure 2.4. Percent of Fully Computerised Clinics by Sector in 2012
Source: Table 2.5
In the public clinics, overall computer usage was 25.0%, which was lower compared with the private clinics (68.3%). Khoo
and Tan in 1998 recorded 43.0% of the private clinics having a computer in their premises for a variety of usage including
word processing, accounting, recording drug stocks, patient record and research.10 Results from this study show that most
of the computers were used for billing purposes (81.7%) and patient’s registration (80.5%) in private clinics (Figure 2.5).
Figure 2.5 also shows that public clinics with computers were using the technology mostly for registration (82.4%), keeping
patient records and dispensing (both at 76.5%). Despite the implementation of Teleprimary Care (TPC) in the government
clinics for the past 7 years, only 88 public primary healthcare facilities were equipped with this system in 2011.TPC allows
tele-consultation in real time within the same state, and has the function for electronic health record keeping.11
Findings on types of computer usage by states and sector can be found in Appendix 1 Table A1.3.
Figure 2.5.Types of Computer Usage by Sector in 2012
6
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
References
1.
Declaration of Alma-Ata. The International Conference on Primary Health Care. Alma-Ata, USSR: World Health Organization, 6-12 September
1978.
2.
Starield B. Primary care: balancing health needs, services, and technology. Revised edition. USA: Oxford University Press, 1998.
3.
Clinical Research Centre. National Healthcare Establishment & Workforce Statistics (Primary Care) 2008-2009. Kuala Lumpur 2011.
4.
Australian Bureau of Statistics. 8865.0 - Private medical practices, Australia 2001-02. Australia. 18th December 2003.
5.
Clinical Research Centre. National Healthcare Establishment & Workforce Statistics (Primary Care) 2010. [unpublished report].
6.
Canadian Labour and Business Centre for Task Force Two: A Physician Human Resource Strategy for Canada. Physician workforce in Canada:
Literature Review and Gap Analysis. Ottawa, Canada: January 2003. [viewed 18th September 2013] Available from: http://www.effectifsmedicaux.ca/
reports/literatureReviewGapAnalysis-e.pdf
7.
Rorem CR. Economics of private group practice. Can Med Assoc J. 1954;70(4):462-6.
8.
Stead WW, Lin HS. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. National Research Council of the
National Academies, Washington, DC: The National Academies Press,2009. [pre publication copy] [viewed 18th September 2013]. Available from http://
www.nlm.nih.gov/pubs/reports/comptech_prepub.pdf
9.
Electronic Patient Record. NHS Institute for Innovation and Improvement, 2013. [ viewed 19th September 2013]. Available from: http://www.
institute.nhs.uk/building_capability/technology_and_product_innovation/electronic_patient_record.html.
10. Khoo EM, Tan PL. Proile of general practices in Malaysia. Asia Pac J Public Health. 1998;10(2): 81-87
11. Ministry of Health Malaysia. Annual Report Ministry of Health 2011. Malaysia:Ministry of Health, 2011.
7
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
Tables for Figures
Table 2.2. Number of Malaysian Primary Care Clinics per 10,000 Population in 2011
State
No. of clinics
Population
Malaysia
6,069
2,89,64,300
2.1
635
16,94,500
3.7
WP Kuala Lumpur
Selangor
Per 10,000 population
1,448
55,77,400
2.6
Negeri Sembilan
267
10,42,900
2.6
Pulau Pinang
400
15,93,600
2.5
Melaka
193
8,33,000
2.3
Perak
554
23,97,600
2.3
Johor
753
34,01,800
2.2
Pahang
270
15,24,800
1.8
Kedah
337
19,73,100
1.7
Terengganu
174
10,74,000
1.6
Perlis
38
2,37,500
1.6
Sarawak
402
25,16,200
1.6
Kelantan
240
16,15,200
1.5
WP Putrajaya
10
76,400
1.3
WP Labuan
10
89,800
1.1
Sabah
338
33,16,400
1.0
Table 2.3.Types of Private Practice by State/Region in 2012
Group practice
State/Region
Solo practice
No. of clinics
No.
Percent (%)
No.
Percent (%)
Selangor & WP Putrajaya
52
15
28.8
37
71.2
WP Kuala Lumpur
30
10
33.3
20
66.7
Kelantan
25
4
16.0
21
84.0
Kota Kinabalu
9
1
11.1
8
88.9
Kuching
4
0
0.0
4
100.0
Overall
120
30
25.0
90
75.0
Table 2.4. Median Attendances per Clinic per Day by State/Region and Sector in 2011
Attendances per day
State/Region
Sector
Total attendances per day
No. of clinics
Median *(IQR)
Public
12,174
34
248.1 (236.2)
Private
2,265
52
40.0 (28.0)
Public
2,611
8
264.6 (119.5)
Private
948
30
30.0 (21.0)
Public
3,271
18
169.9 (112.9)
Private
1,006
25
40.0 (30.0)
Public
1,657
4
390.7 (388.4)
Private
260
8
32.5 (16.0)
Public
2,078
4
463.7 (699.3)
Private
190
4
50.0(43.0)
Selangor & WP Putrajaya
WP Kuala Lumpur
Kelantan
Kota Kinabalu
Kuching
*Median attendances per day
8
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
Table 2.5. Percent of Fully Computerised Clinics by Sector in 2012
Fully computerised clinics
No. of clinics with
computers
No.
Percent (%)
Public
17
2
11.8
Private
82
27
32.9
Total
99
29
29.3
Sector
*the denominator is the total number of clinics with computer system in our sample (n=99)
Table 2.6.Types of Computer Usage by Sector in 2012
Types of computer usage
No. of
clinics with
computer
system
No.
Percent (%)
No.
Percent (%)
No.
Percent (%)
No.
Percent (%)
Public
17
14
82.4
13
76.5
3
17.6
13
76.5
Private
82
66
80.5
49
59.8
67
81.7
37
45.1
Total
99
80
80.8
62
62.6
70
70.7
50
50.5
Sector
Registration
Patient record
9
Billing
Dispensing
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
CHAPTER 3
PRIMARY CARE
| PRIMARY HEALTHCARE FACILITIES
This chapter examines the availability of facilities in our primary care clinics. There are ive variables which are reported
in this chapter; triage system, pharmacy space, imaging and diagnostic room, laboratory space and ambulance services.
Triage system is described as the process of sorting out clients according to their clinical or healthcare needs.1 This is
a system which assesses how quickly a patient needs to be treated while ensuring every patient is given a chance for
appropriate level of care. Triaging patients was previously done only in hospital emergency departments but of late, the
primary care clinics have also implemented this system. One example of effective triaging could be observed in Putrajaya
Health Clinic.1 Currently 55 out of 68 public clinics (80.1%) were observed to practise triaging in their clinics. However,
this study revealed that Kuching had the least number of public clinics set up with facilities to triage patients (50.0%). As
for private sector, the number of clinics offering triaging was even lesser. The highest percentage reported was 34.6% in
Selangor & WP Putrajaya (Table 3.1).
In terms of pharmacy space, it is apparent from Table 3.1 that all public clinics had a pharmacy space in their establishments.
In the public sector, the supplies of medicines are under the responsibility of the pharmacy department. The general
operational policies state that outpatient pharmacy services should be available in public clinics in accordance to the
guidelines on the requirement for the pharmacy facilities.2 As for the private sector, almost all the clinics had a dedicated
pharmacy space in their clinics (Table 3.1).
Having a diagnostic imaging room would usually mean the clinic provides X-ray services. These X-ray facilities require a
speciic room to be built according to the standard requirements.3 The results obtained from the study show that except
for public clinics in Kuching, less than 50.0% of the clinics had this facility (Table 3.1). Similarly, very few private clinics
reported the availability of this facility. None of the private clinics in East Malaysia had this facility.
Table 3.1. Types of Facilities by State/Region and Sector in 2012
Triage system
State/Region
Selangor &
WP Putrajaya
WP Kuala Lumpur
Kelantan
Kota Kinabalu
Kuching
Sector
Pharmacy space
No. of clinics
Diagnostic/
imaging room
No facilities*
No.
Percent (%)
No.
Percent (%)
No.
Percent (%)
No.
Percent (%)
Public
34
25
73.5
34
100.0
12
35.3
0
0.0
Private
52
18
34.6
49
94.2
15
28.8
1
1.9
Total
86
43
50.0
83
96.5
27
31.4
1
1.2
Public
8
8
100.0
8
100.0
3
37.5
0
0.0
Private
30
7
23.3
27
90.0
7
23.3
3
10.0
Total
38
15
39.5
35
92.1
10
26.3
3
7.9
Public
18
16
88.9
18
100.0
4
22.2
0
0.0
Private
25
6
24.0
25
100.0
2
8.0
0
0.0
Total
43
22
51.2
43
100.0
6
14.0
0
0.0
Public
4
4
100.0
4
100.0
1
25.0
0
0.0
Private
9
3
33.3
9
100.0
0
0.0
0
0.0
Total
13
7
53.8
13
100.0
1
7.7
0
0.0
Public
4
2
50.0
4
100.0
4
100.0
0
0.0
Private
4
0
0.0
4
100.0
0
0.0
0
0.0
Total
8
2
25.0
8
100.0
4
50.0
0
0.0
*No facilities refer to clinics having none of the mentioned facilities.
11
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
The availability of laboratory space and functioning ambulance services were captured only in public clinics as most of
the private clinics do not offer these services. All public clinics with an exception of WP Kuala Lumpur (62.5%) had a
speciic laboratory space (Figure 3.1). As for ambulance services, WP Kuala Lumpur has implemented call centre services
which provide ambulance services to clinics based on the distance of the primary care clinic to the call centre; hence
explaining the low reporting of ambulance services. In addition, two of the states sampled in this survey reported not
having fully functioning ambulances. Overall, there was a median of 1.0 (IQR 0.0) functioning ambulances per clinic in the
states/regions sampled (Table 3.2). Similarly, the MOH Annual Report has also reported that only 71.0% ambulances were
functioning in 2011.4
Figure 3.1. Percent of Public Clinics with Laboratory Space and Ambulance Services by State/Region in 2012
Table 3.2. Distribution of Functioning Ambulances in Public Clinics by State/Region in 2012
No. of clinics with
ambulances
No. of functional
ambulances
Selangor & WP Putrajaya
32
33
1.0 (0.0)
WP Kuala Lumpur
3
3
1.0 (0.0)
Kelantan
17
21
1.0 (0.5)
Kota Kinabalu
4
6
1.0 (1.5)
State/Region
Kuching
Total
Median*(IQR)
4
4
1.0 (0.0)
60
67
1.0 (0.0)
*median ambulances per clinic
References
1.
Nora’i MS, Jumiatin O, Farizah H. Effective triaging in Putrajaya Health Clinic. Malaysian Journal of Public Health Medicine. 2002;2(2):58-62.
2.
Pharmaceutical Services Division, Ministry of Health Malaysia. Requirement for the Development of Pharmacy Facilities in Hospitals, Health Clinics and
Other Health Facilities, Ministry of Health, Malaysia. 3rd ed. Pharmaceutical Services Division, Ministry of Health, Malaysia, 2009.
3.
Guidelines to Obtain Class C License under the Atomic Energy Licensing Act (Act 304) from the Ministry of Health Malaysia. Engineering Services Division,
Ministry of Health Malaysia, November 2000. [ viewed 18th September 2013] Available from: http://www.radiologymalaysia.org/Archive/ile%20downloads/
Class%20C%20License%20Guideline_Part2.pdf
4.
Ministry of Health Malaysia. Annual Report Ministry of Health 2011. Malaysia: Ministry of Health, 2011.
12
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
Table for Figures
Table 3.3. Percent of Public Clinics with Laboratory Space and Ambulance Services by State/Region in 2012
Laboratory space
State/Region
Ambulance services
No. of clinics
No.
Percent (%)
No.
Percent (%)
Selangor & WP Putrajaya
34
34
100.0
32
94.1
WP Kuala Lumpur
8
5
62.5
3
37.5
Kelantan
18
18
100.0
17
94.4
Kota Kinabalu
4
4
100.0
4
100.0
Kuching
4
4
100.0
4
100.0
68
65
95.6
60
88.2
Total
13
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
CHAP
NCRC/HSU/2013.2
EDITED BY:
HWONG WY, SIVASAMPU S,
AISYAH A, SHANTHA KUMAR C,
GOH PP, HISHAM AN
NATIONAL HEALTHCARE
E S TA B L I S H M E N T &
WORKFORCE STATISTICS
PRIMARY CARE
2012
N AT I O N A L H E A LT H C A R E S TAT I S T I C S I N I T I AT I V E
National Healthcare Establishment and Workforce Statistics (Primary Care) 2012
March 2014
© Ministry of Health Malaysia
Published by:
The National Healthcare Statistics Initiative (NHSI)
National Clinical Research Centre
National Institutes of Health
3rd Floor, MMA House
124, Jalan Pahang
53000 Kuala Lumpur
Malaysia
Tel.
:
(603) 40439300
Fax
:
(603) 40439400
:
hsu@crc.gov.my
Website :
http://www.crc.gov.my/nhsi
This report is copyrighted. Reproduction and dissemination of its contents in part or in whole for research, educational or
non-commercial purposes is authorised without any prior written permission provided the source is fully acknowledged.
Suggested citation:
Hwong WY, Sivasampu S, Aisyah A, Shantha Kumar C, Goh PP, Hisham AN. National Clinical Research Centre.
National Healthcare Establishment & Workforce Statistics (Primary Care) 2012.
Kuala Lumpur 2014.
This report is also available electronically on the website of the National Healthcare Statistics Initiative at:
http://www.crc.gov.my/nhsi/
Funding:
The National Healthcare Statistics Initiative was funded by a grant from the Ministry of Health Malaysia
(MRG Grant No. NMRR-09-842-4718)
Please note that there is potential for minor corrections of data in this report. Please check the online version at
www.crc.gov.my for any amendments
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
TABLE OF CONTENTS
ACKNOWLEDGEMENTS
iii
PROJECT TEAM
iv
ABBREVIATIONS AND SYMBOLS
v
INTRODUCTION
Background
vi
vi
Objectives
vi
METHODOLOGY
Sampling Frame and Sample Size Calculation
Data Collection and Follow-Up
Data Entry
Data Cleaning and Veriication
Statistical Analysis
Ethical Issues
Limitations
Consort Diagrams
RESPONSE RATE
vii
vii
viii
ix
ix
ix
ix
x
xi
xiii
CHAPTER 1 | OVERVIEW
1
CHAPTER 2 | PRIMARY HEALTHCARE ESTABLISHMENTS
3
4
4
5
8
Types of Private Practice
Attendances
Electronic Healthcare Computer System
Tables for Figures
CHAPTER 3 | PRIMARY HEALTHCARE FACILITIES
Tables for Figures
11
13
CHAPTER 4 | PRIMARY HEALTHCARE SERVICES
15
15
16
16
17
20
Types of Services
Antenatal Care
Laboratory Services
Operating Days and Operating Hours
Tables for Figures
CHAPTER 5 | PRIMARY HEALTHCARE WORKFORCE
Characteristics of Healthcare Providers: Age, Gender and Years of Experience
Working Hours and Full-Time Equivalence
Family Medicine Specialists
Other Healthcare Professionals
Tables for Figures
CHAPTER 6 | PRIMARY HEALTHCARE MEDICAL DEVICES
Tables for Figures
23
23
25
26
27
29
31
35
APPENDICES
APPENDIX 1 | ADDITIONAL TABLES
37
APPENDIX 2 | PARTICIPANTS OF NHEWS PRIMARY CARE 2012
39
APPENDIX 3 | LIST OF DEFINITIONS
43
i
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
LIST OF TABLES
Table 2.1.
Percent of Clinics with Electronic Healthcare Computer System in 2012
5
Table 2.2.
Number of Malaysian Primary Care Clinics per 10,000 Population in 2011
8
Table 2.3.
Types of Private Practice by State/Region in 2012
8
Table 2.4.
Median Attendances per Clinic per Day by State/Region and Sector in 2011
8
Table 2.5.
Percent of Fully Computerised Clinics by Sector in 2012
9
Table 2.6.
Types of Computer Usage by Sector in 2012
9
Table 3.1.
Types of Facilities by State/Region and Sector in 2012
11
Table 3.2.
Distribution of Functioning Ambulances in Public Clinics by State/Region in 2012
12
Table 3.3.
Percent of Public Clinics with Laboratory Space and Ambulance Services by State/Region in 2012
13
Table 4.1.
Percent of Clinics providing Antenatal Services by State/Region and Sector in 2012
16
Table 4.2.
Types of Services Available by Sector in 2012
20
Table 4.3.
Types of Laboratory Services by State/Region and Sector in 2012
20
Table 4.4.
Number of Operating Days per Week in Private Clinics by State/Region in 2012
20
Table 4.5.
Number of Operating Hours per Day in Private Clinics by State/Region in 2012
21
Table 4.6.
Types of Operating Hours per Day in Public Clinics by State/Region in 2012
21
Table 5.1.
Distribution of Medical Doctors by State/Region and Sector in 2012
23
Table 5.2.
Types of Post-Graduate Qualiications for Family Medicine Specialists by Sector in 2012
27
Table 5.3.
Distribution of Other Healthcare Professionals by State/Region and Sector in 2012
28
Table 5.4.
Age Distribution of Medical Doctors by State/Region and Sector in 2012
29
Table 5.5.
Years of Experience of Medical Doctors by State/Region and Sector in 2012
29
Table 5.6.
Gender Distribution of Medical Doctors by Sector In 2012
29
Table 5.7.
Median Working Hours per Week per Doctor by State/Region and Sector In 2012
30
Table 5.8.
Number of Patients Seen per Day per FTE Private Clinic Doctor by State/Region in 2012
30
Table 5.9.
Distribution of Family Medicine Specialists by State/Region and Sector in 2012
30
Table 6.1.
Distribution of Functioning Medical Devices per Clinic by State/ Region and Sector in 2012
Table 6.2.
Percent of Clinics with Functioning Medical Devices by Sector in 2012
35
Table A1.1.
Median Number of Attendances per clinic per year by State/Region and Sector in 2011
37
Table A1.2.
Median Number of Attendances (Outpatient, Home Visit, Antenatal Visit) per clinic per year by
State/Region and Sector in 2011
37
Table A1.3.
Types of Computer Usage by State/Region and Sector in 2012
37
Table A1.4.
Types of Services Available by State/Region and Sector in 2012
38
ii
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ACKNOWLEDGEMENTS
The National Healthcare Statistics Initiative Primary Care team would like to thank the Director General of Health
Malaysia for his continuous support towards this survey and the permission to publish this report.
We would also like to express our sincere appreciation to the following for their participation, assistance, support and
contribution:
● Deputy Director General of Health (Research and Technical Support), MOH
●
Deputy Director General of Health (Public Health), MOH
●
Deputy Director General of Health (Medical), MOH
●
Director, National Clinical Research Centre (NCRC), National Institutes of Health (NIH)
●
Director, Family Health Development Division, MOH
●
Director, Medical Practice Division, MOH
●
State level Private Medical Practice Control Units (Unit Kawalan Amalan Perubatan Swasta, UKAPS) of Kelantan, Sabah,
Sarawak, Selangor and Wilayah Persekutuan Kuala Lumpur.
●
Malaysian Medical Council, Malaysian Medical Association, Academy of Family Physicians Malaysia, National
Specialist Register
Our special thanks and gratitude also goes to
●
All medical doctors and support personnel from the participating public and private clinics whom have kindly provided
data on their respective establishment and workforce
●
The team from Family Health Development Division, MOH whom have generously shared data on public primary
care establishment and workforce
And all those who have supported or contributed to the success of the NHEWS Primary Care Survey 2012 and the
publication of this report
Thank you.
National Healthcare Statistics Initiative (NHSI) Primary Care Team
Healthcare Statistics Unit
National Clinical Research Centre (NCRC)
Ministry of Health, Malaysia
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PROJECT TEAM
Principal Investigator
Datuk Dr. Noor Hisham Abdullah
Dr Sheamini Sivasampu
Principal Co-Investigators
Dr. Goh Pik Pin
Dr Kamaliah Mohd. Noh
Dr. Kaviyarasan Sailin
Professor Dr. Khoo Ee Ming
Research Evaluation Committee
Associate Professor Dr. Ng Chirk Jenn
Professor Dr. Tauik Teng Cheong Lieng
Associate Professor Dr. Jamaluddin Abdul Rahman
Project Manager
Dr. Hwong Wen Yea, Amy
Survey Coordinator
Ms. Aisyah Ali
Research Oficers
Ms. Sharmini Chandran
Ms. Hanan Hamimi Wahid
Dr. Hwong Wen Yea, Amy
Data Analysts
Ms. Norazida Ab Rahman
Mr. Shanthakumar Chandrasekaran
Database Developer/Administrator
Altus Solutions Sdn. Bhd.
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
ABBREVIATIONS AND SYMBOLS
CKAPS
Cawangan Kawalan Amalan Perubatan Swasta
CI
Conidence Interval
CRF
Case Report Form
df
Degree of Freedom
DG
Director General of Health, Ministry of Health Malaysia
e-CRF
Electronic Case Report Form
FAFP
Florida Academy of Family Physician
FMS
Family Medicine Specialist
FRACGP
FRCGP
Fellowship of the Royal Australian College of General Practitioners
Fellowship of Royal College of General Practitioners
FTE
Full Time Equivalence
GP
General Practitioner
IQR
Interquartile Range
KK
Klinik Kesihatan
MOH
MRCGP
MREC
NA
NCRC
NHEWS
NHSI
Ministry of Health
Member of Royal College of General Practitioners
Medical Research Ethics Committee
Not Available
National Clinical Research Centre
National Healthcare Establishment and Workforce Survey
National Healthcare Statistics Initiative
NIH
National Institutes of Health
NMCS
National Medical Care Survey
No.
Number
SD
Standard Deviation
UKAPS
WHO
WP
-
Unit Kawalan Amalan Perubatan Swasta
World Health Organisation
Wilayah Persekutuan
Not Applicable
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
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INTRODUCTION
Background
The National Healthcare Statistics Initiative (NHSI) is a family of surveys looking into services, healthcare workforce,
processes of care as well as some medical technologies of our dual healthcare system.This initiative is part of the Ministry
of Health Malaysia’s (MOH) move towards the availability of better health statistics. Healthcare statistics is a key element
of any country’s policymaking, monitoring and evaluation system. NHSI was initiated in 2009 by the National Clinical
Research Centre (NCRC) in collaboration with relevant MOH and private sector stakeholders. The Healthcare Statistics
Unit (HSU) in NCRC is the program coordinator of this initiative. Over the past 4 years, the NHSI has managed to
gain recognition as a reliable source of healthcare statistics providing useful and timely data which ills the gap between
research and policy.
It is well established that primary care services act as the gatekeeper of any healthcare system. The development of both
National Healthcare Establishment and Workforce Primary Care Survey (NHEWS) and National Medical Care Survey
(NMCS) was mooted when it was realised that there was very little known at large about the primary care system in
Malaysia; especially on the resources and contribution of the private primary care clinics and their providers. Being one
of the four surveys in NHSI, the NHEWS Primary Care Survey is in its third year of inception with two prior surveys
conducted in 2009 and 2010 respectively. In 2012, the project team had decided to pilot test the revised version of NMCS;
hence downsizing NHEWS Primary Care 2012 in terms of national representation.
Objectives
General Objectives
NHEWS Primary Care aims to:
1. determine the availability and distribution of primary healthcare services, facilities and healthcare workforce
2. compare the services, facilities and workforce in primary care between the public and private
3. monitor the trends of the services, facilities and workforce in primary care
4. provide reliable data for the purpose of healthcare planning, policy making and healthcare expenditure
Speciic Objectives
NHEWS 2012 collects primary care data on:
1.
the total number and density of primary care clinics at national level by states and sector
2.
the availability and distribution of primary care facilities and services in the chosen states (Selangor & Wilayah
Persekutuan (WP) Putrajaya,WP Kuala Lumpur and Kelantan) and regions (Kota Kinabalu and Kuching) by sector
3.
the socio-demographics and characteristics of medical doctors and allied healthcare personnel in the chosen
states (Selangor & WP Putrajaya, WP Kuala Lumpur and Kelantan) and regions (Kota Kinabalu and Kuching) by
sector
4.
the distribution of selected medical devices in the chosen states (Selangor & WP Putrajaya,WP Kuala Lumpur and
Kelantan) and regions (Kota Kinabalu and Kuching) by sector
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METHODOLOGY
General
NHEWS 2012 was a cross-sectional study. Random sampling was performed on the primary care clinics in 5 selected
regions which include:
• Kelantan to relect East Coast of Peninsular Malaysia
•
WP Kuala Lumpur, WP Putrajaya and Selangor to relect West Coast of Peninsular Malaysia
•
Kuching and Kota Kinabalu to relect East Malaysia
Approval for NHEWS Primary Care protocol was granted by MOH Medical Research and Ethics Committee (MREC) in 2010.
Sampling Frame and Sample Size Calculation
The determination of total population for the survey was inalised prior to the initiation of data collection. This involved
record matching of clinics from the NHEWS Primary Care 2010 list against independent databases from Ministry of Health’s
Private Medical Practice Control Section (CKAPS) and Family Health Development Division. Checking of duplicates and
matching were done by the Information Technology (IT) department. Both matched and unmatched records were then
reviewed by NHEWS Primary Care team and subsequent veriication was conducted by contacting each site to conirm
their operational status. The review and veriication processes were repeated and closed clinics were removed from the
sampling frame.
The inclusion and exclusion criteria for the survey were as stated below:
INCLUSION
CRITERIA
EXCLUSION
CRITERIA
•
All private medical clinics registered with the Medical Practice Control Section or Cawangan
Kawalan Amalan Perubatan Swasta (CKAPS) providing primary care (up to 31st December 2011)
•
All MOH Health Clinics (Klinik Kesihatan) delivering outpatient services by medical doctors. (up to
31st December 2011)
•
Government clinics which fell into the categories of:
- Outpatient departments within public hospitals
- Klinik Kesihatan without medical doctors
- Clinics providing maternal and child health services only (Klinik Kesihatan Ibu dan Anak)
- Rural Clinics (Klinik Desa)
- 1 Malaysia Clinics
- Primary care clinics in universities
•
Private Clinics which fell into the categories of:
• In-house clinics /company clinics
• Clinics providing specialised care/ Specialist clinics e.g. paediatric, cardiology, occupational therapy
• Diagnostic centres
• Aesthetic clinics
• Charity clinics
The random sampling method used for sample size calculation was a complex multistage stratiied random sampling.
Stages for the sampling involved:
Stage 1: Selection of Sampling Regions (Convenience / Purposive Sampling)
• WP Kuala Lumpur, Selangor and WP Putrajaya, Kelantan, Kuching and Kota Kinabalu
Stage 2: Stratiication by Sector
• Each region was stratiied to both public and private sector.
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
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Stage 3: Sampling of Clinics
• Random sampling was done based on random numbers generated from Microsoft Excel. During the sampling, the
inclusion and exclusion criteria for both public and private sectors were accounted for.
The table below shows the inal calculated sample size:
Sample Size for NHEWS Primary Care 2012
State/Region
No. of clinics
Public
Private
Selangor & WP Putrajaya
39
187
WP Kuala Lumpur
8
107
Kelantan
20
57
Kuching
4
21
Kota Kinabalu
4
11
75
383
Total
Data Collection and Follow-Up
These sampled clinics were sent an oficial invitation letter to attend a brieing. Brieings for government doctors were held on
weekdays whereas for private doctors, brieings were conducted on the weekends between June and July 2012.
During the brieings, doctors who attended were given a research pack which contained:
•
Call letter for participation of the survey signed by State Director of Health
•
Case report form (CRF)
•
Username and password for the option of completing the survey form online
•
Prepaid envelope
•
NHEWS Primary Care 2008-2009 report
Clinics which did not send any representatives for the brieings were contacted by phone in an attempt to persuade them
to participate. Many strategies were carried out to increase the response rate of the sampled private clinics.
These included:
• Establishing buy in from senior management of the chain clinics
•
Close cooperation with the state Malaysian Medical Association (MMA) to encourage their members to participate
•
Conducting private brieings to the doctor/nurse-in-charge of primary care clinics around KL/Selangor region
•
Establishing a close rapport with medical enforcements’ oficers of the respective states and regions. At times, the
project team followed the enforcement oficers during their scheduled visits and conducted a private brieing to the
sampled clinics.
•
Contacting clinics via phone. If the doctor agreed to participate, a research pack was sent by express post. This was
followed by a telephone call to conirm that the research pack had been received and a brieing over the phone was
then conducted.
Respondents to this survey had 2 options for modes of data submission which were:
• Paper data submission via hardcopy of the Case Report Form (CRF)
• Electronic data submission via web application (eCRF)
For clinics which failed to return their forms, they were reminded via phone calls. Such reminders were made for both
surveys (NMCS 2012 and NHEWS Primary Care 2012) simultaneously in two stages, ie at 3 weeks and at 5 weeks
after their respective survey dates for NMCS 2012. All participants were encouraged to contact the research team with
questions, at any time during ofice hours by phone.
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Once the survey forms were received either by postage or online, two certiicates and a copy of the NMCS 2010 report
were sent to the participants as a token of appreciation.
Data Entry
Data received via paper submission were thoroughly reviewed for completeness and consistency prior to data entry
into the NHEWS Primary Care database. Data entry was then performed by trained NHEWS Primary Care members.
Data entry from participant’s site through eCRF was submitted directly into the NHEWS Primary Care database and
monitored in real-time basis by the members of the team. Quality of data entry was constantly checked and maintained
by several built-in features in the data entry module such as a compulsory data checking function, inconsistency checks,
auto calculations and auto default data from previous year’s survey. Every activity in the database was recorded in a realtime tracking system.
Data Cleaning and Veriication
Data cleaning was performed in parallel with data entry based on the results of edit checks. An edit check is a data
checking procedure for tracing doubtful data being entered and was performed by NHEWS Primary Care team members
who are familiar with primary care settings. A built in data query feature was also created in the web application to cross
check data from the same variables in 2010 and 2012. Queries that arose were then attended to by contacting the stated
person-in-charge in the form or other authorised representatives to seek further clariication.
All queries were resolved before the database was locked to maintain data quality and integrity. A inal checking was
performed prior to database locking to ensure that the data was acceptable for statistical analysis. The dataset was
then standardised by performing data deduplication procedure for removing duplicate records and checking of range
and consistency to detect outliers. A protocol with validation rules for cleaning as well as data inconsistency rules have
been created for data cleaning. Cross-checking with other relevant data sources such as the Malaysian Medical Council
database, National Specialist Register of Malaysia and list of registered family medicine specialists from the Academy of
Family Physician Malaysia was performed. Most of the missing or out-of-range mandatory variables and auxiliary variables
were resolved during data cleaning stage.
Statistical Analysis
Findings of the survey were primarily reported as descriptive statistics. Statistical analyses were conducted using the
IBM SPSS Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp). Categorical data were reported in rates and
proportions but their respective conidence intervals were not reported as the requirements for inferential statistics
were not met.1 Proportions may not always add up to exactly 100.0% due to rounding of igures. Continuous data were
reported in median and interquartile range (IQR). An analysis to determine if there were any signiicant differences
between the characteristics of the respondents and non-respondents from the private general practitioners (GPs) namely
age, gender and years of practice was also conducted. Categorical variables were compared using the χ2-test whereas for
continuous variables; a simple logistic regression.
Ethical Issues
As mentioned above, the survey received ethics approval from Medical Research and Ethics Committee (MREC) of the
MOH. As participation in this study was on voluntary-basis, respondents had the right to decline to participate at any
point of time throughout the study.
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Limitations
1. Only 3 states (Selangor and WP Putrajaya,WP Kuala Lumpur and Kelantan) and 2 regions (Kota Kinabalu and Kuching)
were selected in the survey. The results of this study do not relect national or state representation for Sabah and
Sarawak.
2. The same sample size calculation was used for both NHEWS Primary Care 2012 and NMCS 2012. Further details of
the calculation can be found in the NMCS 2012 report2.
3. The sample was not calculated to represent each type of (Type I to Type VI) clinics in the public sector.
4. The survey was rolled out in July 2012 and hence, data on the number of clinics and total attendances could only be
reported as of the year 2011 as those variables were collected yearly. The rest of the variables were reported as of
30th of June 2012.
5. The results could not be inferred to the population because to our best knowledge, there was a lack of a reliable
national representation of both health sectors for the purpose of applying survey weights.
References
1.
Naing L. Inferential Statistics. Power point presentation. Research Methodology and Basic Biostatistics Workshop, Kuala Lumpur. 23rd-25th
August 2013.
2.
Sivasampu S, Yvonne Lim, Hwong WY, Norazida AR, Goh PP, Hisham AN. National Clinical Research Centre. National Medical Care
Statistics 2012. (unpublished report)
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
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CONSORT DIAGRAM: PUBLIC PRIMARY CARE CLINICS 2012 (KLINIK KESIHATAN)
Excluded
*Kuching and Kota Kinabalu regions were taken to represent Sarawak and Sabah respectively
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
CONSORT DIAGRAM: PRIVATE PRIMARY CARE CLINICS 2012
*Kuching and Kota Kinabalu regions were taken to represent Sarawak and Sabah respectively
xii
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
RESPONSE RATE
The table below shows the response rate for NHEWS Primary Care 2012 Survey:
Response Rate for NHEWS Primary Care 2012 Survey
State/Region
Sector
Sample size
No. of respondents
Response rate (%)
Selangor & WP Putrajaya
Public
39
34
87.2
Private
187
52
27.8
WP Kuala Lumpur
Kelantan
Kota Kinabalu
Kuching
Overall
Public
8
8
100.0
Private
107
30
28.0
Public
20
18
90.0
Private
57
25
43.9
Public
4
4
100.0
Private
21
9
42.9
Public
4
4
100.0
Private
11
4
36.4
Public
75
68
90.7
Private
383
120
31.3
The low response rate from private clinics had already been anticipated and accounted for. A few studies which previously
surveyed private clinics in Malaysia had also reported similar response rates ranging from 26.3% to 33.0%.1,2 Low response
rates in national surveys when physicians were the responders had been associated with many factors such as apathy, lack
of incentives and resistant to healthcare surveys especially those conducted by the government.3,4
In view of this, the sampling matrix calculation had included an estimation of a 30.0% drop-out rate from the public and a
70.0% drop-out rate from the private sector.
A subsequent analysis comparing the respondents and non-respondents from private clinics was performed to ensure
that the low response rate has not introduced any form of bias into the indings. As seen from the tables below, no
signiicant differences in terms of age, gender and years of practice between these two GP groups were observed.
Comparison of age between the respondents and non-respondents in the private sector
Characteristics
Odds ratio
95% CI for
odds ratio
χ2 statistics (df)
P value
1.01
(0.99, 1.03)
0.27 (1)
0.604
Age
*10 missing variables for non respondents
Comparison of gender between the respondents and non-respondents in the private sector
Characteristics
n
Respondents
n (%)
Non respondents
n (%)
χ2 statistic (df)
P value
0.04(1)
0.837
Gender
Male
239
76 (31.8)
163 (68.2)
Female
134
44 (32.8)
90 (67.2)
*10 missing variables for non respondents
Comparison of years of practice between the respondents and non-respondents in the private sector
Characteristics
Odds ratio
95% CI for
Odds ratio
Years of Practice
1.00
(0.98, 1.03)
χ2 statistics (df)
0.15 (1)
P value
0.699
*4 missing variables for respondents and 14 missing variables for non respondents
Having this analysis also increased the validity of the study. As the non-respondents were mainly from the private sector,
the team has kept the comparison between the two groups to private sector only.
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
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References
1.
Teng CL,Tong SF, Khoo EM, Lee V, Zailinawati AH, Mimi O, Chen WS, Nordin S.Antibiotics for URTI and UTI – prescribing in Malaysian
primary care settings. Aust Fam Physician. 2011; 40(5):325-9.
2.
Mimi O,Tong SF, Nordin S,Teng CL, Khoo EM, Abdul-Rahman A, Zailinawati AH, Chen WS, Shihabudin WM, Noridah MS, Fauziah ZE. A
comparison of morbidity patterns in public and private primary care clinics in Malaysia. Malaysian Family Physician. 2011; 6(1):19-25
3.
Parsons J, Warnecke R, Czaja R, Barnsley J, Kaluzny A. Factors associated with response rates in a national survey of primary care
physicians. Eval Rev. 1994; 18: 756-66.
4.
Cartwright, A. Professionals as responders: variations in and effects of response rates to questionnaires. BMJ. 1978; 2: 1419-21
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
CHAPTER 1
PRIMARY CARE
| OVERVIEW
Primary care provides essential functions for individual patients, health systems and populations. Apart from managing
and triaging undifferentiated symptoms and delivering treatment for acute and chronic illnesses, primary care providers
also manage many different services which include health promotion, disease prevention, health maintenance, counselling,
patient education and many more.1
The Malaysian primary care is of no exception.The two tiered healthcare system i.e. public and private holds an extremely
important position in the delivery of primary care services in Malaysia. This chapter summarises the key indings of
NHEWS Primary Care Survey 2012 by chapters:
Chapter 2: Primary Healthcare Establishments
• There were 5,198 private clinics and 871 public clinics in Malaysia as of 31st December 2011.
•
Overall, there were 2.1 clinics per 10,000 population in Malaysia.
•
75.0% of the private clinics were solo practices.
•
On average, public clinics had a higher total attendances per day compared to the private.The highest ratio was 12:1 (public
versus private).
•
Only 29.3% of the primary care clinics were fully computerised with the majority coming from private sector.
Chapter 3: Primary Healthcare Facilities
•
55 out of 68 public clinics sampled had a triage system implemented in their clinics.
•
None of the private clinics sampled in East Malaysia had a diagnostic imaging/X-ray room in their premises.
•
All public clinics with an exception of WP Kuala Lumpur (62.5%) had a designated laboratory space.
•
The median for functioning ambulances per public clinic in the states/regions sampled is 1.0 (IQR 0.0).
Chapter 4: Primary Healthcare Services
• Only 16.7% of the private clinics offered smoking cessation programmes as compared to 75.0% in the public.
•
More than 90.0% of public clinics provided preventive and health promotion services such as obstetric and
gynaecological services, family planning services and clinical breast examinations. On the other hand, private clinics
performed more minor surgeries (91.7%) and medical check-ups (98.3%).
•
All states and regions sampled had a higher percentage (range: 51.9% - 75.0%) of clinics opening 7 days in a week
except for WP Kuala Lumpur where 73.3% of the clinics had less than 7 operating days in a week.
•
Only 5.0% of the private clinics in the states/regions sampled were functioning as 24-hour clinics.
Chapter 5: Primary Healthcare Workforce
• The median number of doctors per public clinic was 4.5 doctors (IQR 5.0) and 1.0 doctor (IQR 1.0) per private clinic.
•
The majority of doctors (61.1%) practising in the public clinics were between the ages of 25-34 years old. By
comparison, 72.1% of the private clinics’ doctors were ≥ 45 years old.
•
75.5% of the doctors in the private sector had more than 10 years of experience in primary care.
•
Overall, two-third of the doctors in primary care were females.
•
Medical doctors from private clinics worked a median of 47.5 (IQR 21.0) hours per week while public clinic doctors
had shorter working hours per week with a median of 40.0 (IQR 5.0) hours.
•
Kuching region recorded the highest number of patients seen per day per full time equivalence (FTE) doctor (44 patients).
•
Overall, there was a ratio of 1 Family Medicine Specialist to 5 primary care clinics.
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
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Chapter 6: Primary Healthcare Medical Devices
• Only 51.5% of the public clinics had functioning deibrillators in their premises.
•
Less than 15.0% of the private clinics had laboratory equipments such as bilirubinometer or full blood count analysers.
•
Public clinics had a median of four or more functioning peak low meters per clinic for every state/region while the
private sector had only a median of one functioning peak low meter per clinic.
•
71 out of 73 resuscitation trolleys were functioning in the public clinics. Clinics in both public and private sectors
had at least one resuscitation trolley per clinic except for private clinics in Kelantan which only had a median of 0.6
(IQR 1.0) resuscitation trolley per clinic.
•
About 5.0% of the glucometers in the public clinics were reported to be non-functioning.
Although the survey was restricted to only 3 states and 2 regions sampled, the indings have provided a better understanding
of the primary care services as well as the socio-demographic characteristics of the primary healthcare workforce. These
results, together with the indings of morbidity pattern and processes of care from the National Medical Care Survey
(NMCS) 2012 are hoped to form a clearer picture on the current primary healthcare system in Malaysia.
References
1.
Primary Care. American Academy of Family Physicians, 2013. [Viewed 17th October 2013]. Available from: http://www.aafp.org/about/
policies/all/primary-care.html.
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
CHAPTER 2
PRIMARY CARE
| PRIMARY HEALTHCARE ESTABLISHMENTS
Primary healthcare is the foundation of a comprehensive healthcare system for the nation. Its framework is detailed in
the 1978 Declaration of Alma-Ata.This includes at least the following 8 areas: identifying, controlling and preventing health
conditions through education, adequate nutrition, maternal and child healthcare, immunisation against major infectious
diseases, family planning, prevention and control of local endemic conditions, management of common ailments and
injuries and provision of essential drugs.1 Primary care serves as the irst-contact point and as a gatekeeper to secondary
and tertiary health care.2 This highlights the importance of collecting information on the present workforce and health
services in primary care for evaluation of the current system as well as in drafting and implementation of future health
policies.
The two-tiered healthcare system for primary care in Malaysia; the public and private sectors have provided accessibility
to Malaysians for many years. While the public health system is heavily subsidised by the government, the private clinics
charge fee-for-service. As of 31st December 2011, there were 5,198 private primary care clinics and 871 public primary
care clinics in Malaysia. The ratio of private clinics to public clinics was 6:1. This difference has not changed much from the
6.3:1 ratio reported in 2008-2009.3
In summary there were 2.1 clinics per 10,000 population in Malaysia in 2011 (Figure 2.1). Figure 2.1 also shows a consistently
higher number of clinics per 10,000 population in the urban states of which WP Kuala Lumpur had the highest density; 3.7
clinics per 10,000 population.This density however is still low compared to Australia which recorded an average of 6.1 GP
practices per 10,000 population in 2002.4
Figure 2.1. Number of Malaysian Primary Care Clinics per 10,000 Population in 2011
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
Types of Private Practice
The majority of practices (75.0%) in 2012 were still individual practices. However, there has been an increase in private
group practices in all states sampled over the two year period.5 Clinics in WP Kuala Lumpur recorded the highest
proportion of group practice at 33.3%. A study in 2003 on physician workforce in Canada reported that the trend
of having group practice was more popular among the younger generation of the general practitioners with the aim
to achieve a more balanced lifestyle in terms of workload distribution.6 The changing trend towards group practice is
also hoped to reduce medical error and negligence in primary care when GPs with different skills and knowledge are
brought together for a more comprehensive diagnosis and treatment of patients. Moreover economics wise, forming
group practices would allow better equipments and facilities to be built and shared.7
Figure 2.2.Types of Private Practice by State/Region in 2012
Attendances
Despite being outnumbered in terms of quantity of clinics, the public sector is seeing the bulk of primary care patients
compared to the private clinics. Our results showed that overall, public clinics had higher attendances compared to clinics
in the private sector (Appendix 1 Table A1.1).The difference was obvious in Kota Kinabalu where the number of attendees
to the public clinics per day was approximately 12 times more than that of the private clinics (Figure 2.3).The public clinics
in Kuching region recorded the highest number of attendees in a day with a median of 463.7(IQR 699.3) attendances per
clinic per day.
The breakdown by types of attendances such as antenatal and home visits can be found in the Appendix 1 Table A1.2.
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NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
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Figure 2.3. Median Attendances per Clinic per Day by State/Region and Sector in 2011
Electronic Health Care Computer System
Implementation of a computer system and incorporating information technology in healthcare practices is expected
to play a vital role in the near future especially to acquire, manage and disseminate knowledge and information.8
Among the beneits of using electronic patient record include more eficient transferability of the records, systematic
record keeping where all results and patient notes are kept together, increasing safety of the records and most
importantly, enabling involved GP practitioners to have immediate access to full records.9 Our indings indicate that
more than half (52.7%) of the respondents were already using computers in their establishments (Table 2.1). Out of
these, only 29.3% of these clinics were fully computerised (patient records, dispensing, billing and registration); most
of them from the private sector (Figure 2.4).
Table 2.1. Percent of Clinics with Electronic Healthcare Computer System in 2012
Clinics with computer system
State/Region
Sector
No. of clinics
Selangor & WP Putrajaya
Public
34
WP Kuala Lumpur
Kelantan
Kota Kinabalu
Kuching
Overall
No.
Percent (%)
9
26.5
Private
52
41
78.8
Total
86
50
58.1
Public
8
4
50.0
Private
30
20
66.7
Total
38
24
63.2
Public
18
2
11.1
Private
25
12
48.0
Total
43
14
32.6
Public
4
0
0.0
Private
9
6
66.7
46.2
Total
13
6
Public
4
2
50.0
Private
4
3
75.0
Total
8
5
62.5
Public
68
17
25.0
Private
120
82
68.3
Total
188
99
52.7
5
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
Figure 2.4. Percent of Fully Computerised Clinics by Sector in 2012
Source: Table 2.5
In the public clinics, overall computer usage was 25.0%, which was lower compared with the private clinics (68.3%). Khoo
and Tan in 1998 recorded 43.0% of the private clinics having a computer in their premises for a variety of usage including
word processing, accounting, recording drug stocks, patient record and research.10 Results from this study show that most
of the computers were used for billing purposes (81.7%) and patient’s registration (80.5%) in private clinics (Figure 2.5).
Figure 2.5 also shows that public clinics with computers were using the technology mostly for registration (82.4%), keeping
patient records and dispensing (both at 76.5%). Despite the implementation of Teleprimary Care (TPC) in the government
clinics for the past 7 years, only 88 public primary healthcare facilities were equipped with this system in 2011.TPC allows
tele-consultation in real time within the same state, and has the function for electronic health record keeping.11
Findings on types of computer usage by states and sector can be found in Appendix 1 Table A1.3.
Figure 2.5.Types of Computer Usage by Sector in 2012
6
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
References
1.
Declaration of Alma-Ata. The International Conference on Primary Health Care. Alma-Ata, USSR: World Health Organization, 6-12 September
1978.
2.
Starield B. Primary care: balancing health needs, services, and technology. Revised edition. USA: Oxford University Press, 1998.
3.
Clinical Research Centre. National Healthcare Establishment & Workforce Statistics (Primary Care) 2008-2009. Kuala Lumpur 2011.
4.
Australian Bureau of Statistics. 8865.0 - Private medical practices, Australia 2001-02. Australia. 18th December 2003.
5.
Clinical Research Centre. National Healthcare Establishment & Workforce Statistics (Primary Care) 2010. [unpublished report].
6.
Canadian Labour and Business Centre for Task Force Two: A Physician Human Resource Strategy for Canada. Physician workforce in Canada:
Literature Review and Gap Analysis. Ottawa, Canada: January 2003. [viewed 18th September 2013] Available from: http://www.effectifsmedicaux.ca/
reports/literatureReviewGapAnalysis-e.pdf
7.
Rorem CR. Economics of private group practice. Can Med Assoc J. 1954;70(4):462-6.
8.
Stead WW, Lin HS. Computational Technology for Effective Health Care: Immediate Steps and Strategic Directions. National Research Council of the
National Academies, Washington, DC: The National Academies Press,2009. [pre publication copy] [viewed 18th September 2013]. Available from http://
www.nlm.nih.gov/pubs/reports/comptech_prepub.pdf
9.
Electronic Patient Record. NHS Institute for Innovation and Improvement, 2013. [ viewed 19th September 2013]. Available from: http://www.
institute.nhs.uk/building_capability/technology_and_product_innovation/electronic_patient_record.html.
10. Khoo EM, Tan PL. Proile of general practices in Malaysia. Asia Pac J Public Health. 1998;10(2): 81-87
11. Ministry of Health Malaysia. Annual Report Ministry of Health 2011. Malaysia:Ministry of Health, 2011.
7
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
Tables for Figures
Table 2.2. Number of Malaysian Primary Care Clinics per 10,000 Population in 2011
State
No. of clinics
Population
Malaysia
6,069
2,89,64,300
2.1
635
16,94,500
3.7
WP Kuala Lumpur
Selangor
Per 10,000 population
1,448
55,77,400
2.6
Negeri Sembilan
267
10,42,900
2.6
Pulau Pinang
400
15,93,600
2.5
Melaka
193
8,33,000
2.3
Perak
554
23,97,600
2.3
Johor
753
34,01,800
2.2
Pahang
270
15,24,800
1.8
Kedah
337
19,73,100
1.7
Terengganu
174
10,74,000
1.6
Perlis
38
2,37,500
1.6
Sarawak
402
25,16,200
1.6
Kelantan
240
16,15,200
1.5
WP Putrajaya
10
76,400
1.3
WP Labuan
10
89,800
1.1
Sabah
338
33,16,400
1.0
Table 2.3.Types of Private Practice by State/Region in 2012
Group practice
State/Region
Solo practice
No. of clinics
No.
Percent (%)
No.
Percent (%)
Selangor & WP Putrajaya
52
15
28.8
37
71.2
WP Kuala Lumpur
30
10
33.3
20
66.7
Kelantan
25
4
16.0
21
84.0
Kota Kinabalu
9
1
11.1
8
88.9
Kuching
4
0
0.0
4
100.0
Overall
120
30
25.0
90
75.0
Table 2.4. Median Attendances per Clinic per Day by State/Region and Sector in 2011
Attendances per day
State/Region
Sector
Total attendances per day
No. of clinics
Median *(IQR)
Public
12,174
34
248.1 (236.2)
Private
2,265
52
40.0 (28.0)
Public
2,611
8
264.6 (119.5)
Private
948
30
30.0 (21.0)
Public
3,271
18
169.9 (112.9)
Private
1,006
25
40.0 (30.0)
Public
1,657
4
390.7 (388.4)
Private
260
8
32.5 (16.0)
Public
2,078
4
463.7 (699.3)
Private
190
4
50.0(43.0)
Selangor & WP Putrajaya
WP Kuala Lumpur
Kelantan
Kota Kinabalu
Kuching
*Median attendances per day
8
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
Table 2.5. Percent of Fully Computerised Clinics by Sector in 2012
Fully computerised clinics
No. of clinics with
computers
No.
Percent (%)
Public
17
2
11.8
Private
82
27
32.9
Total
99
29
29.3
Sector
*the denominator is the total number of clinics with computer system in our sample (n=99)
Table 2.6.Types of Computer Usage by Sector in 2012
Types of computer usage
No. of
clinics with
computer
system
No.
Percent (%)
No.
Percent (%)
No.
Percent (%)
No.
Percent (%)
Public
17
14
82.4
13
76.5
3
17.6
13
76.5
Private
82
66
80.5
49
59.8
67
81.7
37
45.1
Total
99
80
80.8
62
62.6
70
70.7
50
50.5
Sector
Registration
Patient record
9
Billing
Dispensing
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
CHAPTER 3
PRIMARY CARE
| PRIMARY HEALTHCARE FACILITIES
This chapter examines the availability of facilities in our primary care clinics. There are ive variables which are reported
in this chapter; triage system, pharmacy space, imaging and diagnostic room, laboratory space and ambulance services.
Triage system is described as the process of sorting out clients according to their clinical or healthcare needs.1 This is
a system which assesses how quickly a patient needs to be treated while ensuring every patient is given a chance for
appropriate level of care. Triaging patients was previously done only in hospital emergency departments but of late, the
primary care clinics have also implemented this system. One example of effective triaging could be observed in Putrajaya
Health Clinic.1 Currently 55 out of 68 public clinics (80.1%) were observed to practise triaging in their clinics. However,
this study revealed that Kuching had the least number of public clinics set up with facilities to triage patients (50.0%). As
for private sector, the number of clinics offering triaging was even lesser. The highest percentage reported was 34.6% in
Selangor & WP Putrajaya (Table 3.1).
In terms of pharmacy space, it is apparent from Table 3.1 that all public clinics had a pharmacy space in their establishments.
In the public sector, the supplies of medicines are under the responsibility of the pharmacy department. The general
operational policies state that outpatient pharmacy services should be available in public clinics in accordance to the
guidelines on the requirement for the pharmacy facilities.2 As for the private sector, almost all the clinics had a dedicated
pharmacy space in their clinics (Table 3.1).
Having a diagnostic imaging room would usually mean the clinic provides X-ray services. These X-ray facilities require a
speciic room to be built according to the standard requirements.3 The results obtained from the study show that except
for public clinics in Kuching, less than 50.0% of the clinics had this facility (Table 3.1). Similarly, very few private clinics
reported the availability of this facility. None of the private clinics in East Malaysia had this facility.
Table 3.1. Types of Facilities by State/Region and Sector in 2012
Triage system
State/Region
Selangor &
WP Putrajaya
WP Kuala Lumpur
Kelantan
Kota Kinabalu
Kuching
Sector
Pharmacy space
No. of clinics
Diagnostic/
imaging room
No facilities*
No.
Percent (%)
No.
Percent (%)
No.
Percent (%)
No.
Percent (%)
Public
34
25
73.5
34
100.0
12
35.3
0
0.0
Private
52
18
34.6
49
94.2
15
28.8
1
1.9
Total
86
43
50.0
83
96.5
27
31.4
1
1.2
Public
8
8
100.0
8
100.0
3
37.5
0
0.0
Private
30
7
23.3
27
90.0
7
23.3
3
10.0
Total
38
15
39.5
35
92.1
10
26.3
3
7.9
Public
18
16
88.9
18
100.0
4
22.2
0
0.0
Private
25
6
24.0
25
100.0
2
8.0
0
0.0
Total
43
22
51.2
43
100.0
6
14.0
0
0.0
Public
4
4
100.0
4
100.0
1
25.0
0
0.0
Private
9
3
33.3
9
100.0
0
0.0
0
0.0
Total
13
7
53.8
13
100.0
1
7.7
0
0.0
Public
4
2
50.0
4
100.0
4
100.0
0
0.0
Private
4
0
0.0
4
100.0
0
0.0
0
0.0
Total
8
2
25.0
8
100.0
4
50.0
0
0.0
*No facilities refer to clinics having none of the mentioned facilities.
11
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
The availability of laboratory space and functioning ambulance services were captured only in public clinics as most of
the private clinics do not offer these services. All public clinics with an exception of WP Kuala Lumpur (62.5%) had a
speciic laboratory space (Figure 3.1). As for ambulance services, WP Kuala Lumpur has implemented call centre services
which provide ambulance services to clinics based on the distance of the primary care clinic to the call centre; hence
explaining the low reporting of ambulance services. In addition, two of the states sampled in this survey reported not
having fully functioning ambulances. Overall, there was a median of 1.0 (IQR 0.0) functioning ambulances per clinic in the
states/regions sampled (Table 3.2). Similarly, the MOH Annual Report has also reported that only 71.0% ambulances were
functioning in 2011.4
Figure 3.1. Percent of Public Clinics with Laboratory Space and Ambulance Services by State/Region in 2012
Table 3.2. Distribution of Functioning Ambulances in Public Clinics by State/Region in 2012
No. of clinics with
ambulances
No. of functional
ambulances
Selangor & WP Putrajaya
32
33
1.0 (0.0)
WP Kuala Lumpur
3
3
1.0 (0.0)
Kelantan
17
21
1.0 (0.5)
Kota Kinabalu
4
6
1.0 (1.5)
State/Region
Kuching
Total
Median*(IQR)
4
4
1.0 (0.0)
60
67
1.0 (0.0)
*median ambulances per clinic
References
1.
Nora’i MS, Jumiatin O, Farizah H. Effective triaging in Putrajaya Health Clinic. Malaysian Journal of Public Health Medicine. 2002;2(2):58-62.
2.
Pharmaceutical Services Division, Ministry of Health Malaysia. Requirement for the Development of Pharmacy Facilities in Hospitals, Health Clinics and
Other Health Facilities, Ministry of Health, Malaysia. 3rd ed. Pharmaceutical Services Division, Ministry of Health, Malaysia, 2009.
3.
Guidelines to Obtain Class C License under the Atomic Energy Licensing Act (Act 304) from the Ministry of Health Malaysia. Engineering Services Division,
Ministry of Health Malaysia, November 2000. [ viewed 18th September 2013] Available from: http://www.radiologymalaysia.org/Archive/ile%20downloads/
Class%20C%20License%20Guideline_Part2.pdf
4.
Ministry of Health Malaysia. Annual Report Ministry of Health 2011. Malaysia: Ministry of Health, 2011.
12
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
PRIMARY CARE
Table for Figures
Table 3.3. Percent of Public Clinics with Laboratory Space and Ambulance Services by State/Region in 2012
Laboratory space
State/Region
Ambulance services
No. of clinics
No.
Percent (%)
No.
Percent (%)
Selangor & WP Putrajaya
34
34
100.0
32
94.1
WP Kuala Lumpur
8
5
62.5
3
37.5
Kelantan
18
18
100.0
17
94.4
Kota Kinabalu
4
4
100.0
4
100.0
Kuching
4
4
100.0
4
100.0
68
65
95.6
60
88.2
Total
13
NATIONAL HEALTHCARE ESTABLISHMENT & WORKFORCE STATISTICS 2012
CHAP