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Contents 1 PRIMARY MEDICAL CARE SECTOR ...... 6
1.1 Strengthening Preventive Activities In Health Clinics ...... 6
1.2 Health Risk Intervention Services ...... 8
1.3 Care of Patient ...... 9
1.4 Treatment of Chronic Disease Complications ...... 13
1.5 Klinik Komuniti ...... 15
2 PRIMARY HEALTH FACILITY INFRASTRUCTURE DEVELOPMENT SECTOR ...... 18
2.1 Primary Health Care Facilities ...... 18
2.2 Standard Design And One Off Design Clinics ...... 19
2.3 Planning For Building Of New Primary Health Care Facility Under Eleventh Malaysia Plan Rolling Plan 4 (RMK 11 – RP4) 2019 ...... 20
2.4 Clinic Support Services [Perkhidmatan Sokongan Klinik (PSK)] ...... 20
2.5 PSK Audit Visit And Project Committee Meeting ...... 21
2.6 Feedback, Comments, Suggestions, Recommendations And Approval ...... 21
2.7 Visits To Health Clinics ...... 22
3 PRIMARY HEALTH CARE INFORMATICS SECTOR ...... 22
3.1 Teleprimary Care (TPC) ...... 22
3.2 Teleprimary Care (TPC) ...... 25
3.3 Teleprimary Care-Oral Health Clinical Information System (TPC-OHCIS) ...... 26
4 CLINICAL AND TECHNICAL SUPPORT SERVICES SECTOR ...... 27
4.1 Human Resource Development in Primary Health Care ...... 27
4.2 Radiology Service ...... 29
4.3 Laboratory services ...... 35
4.4 Medical Equipment Enhancement Tenure (MEET) ...... 39
4.5 Enhanced Primary Health Care Initiative (EnPHC) ...... 41
4.6 Dietetic Services ...... 43
4.7 Pharmacy services ...... 46
5 QUALITY AND INNOVATION SECTOR ...... 50
5.1 Antimicrobial Stewardship Program (AMS) ...... 50
5.2 Malaysian Patient Safety Goals ...... 53
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5.3 Infection Prevention and Control in Primary Health Care ...... 55
5.4 QAP Friendly Clinic and QAP Appropriate Management of Asthma ...... 57
5.5 Waiting Time Monitoring at Health Clinics ...... 59
6 PRIMARY POLICY DEVELOPMENT SECTOR ...... 60
6.1 Health Services In Immigration Depot ...... 60
6.2 Clinical Service After The Office Time (Extended Hour) ...... 64
6.3 Health Clinic Advisory Panel (PPKK) ...... 67
6.4 Family Doctor Concept (FDC) ...... 70
6.5 Mobile Health Services ...... 71
7 PRIMARY EMERGENCY CARE SECTOR ...... 75
7.1 Emergency services ...... 75
7.2 Ambulance Service ...... 79
7.3 Government Integrated Radio Network ...... 83
7.4 Disaster ...... 84
7.5 Treatment Charges ...... 84
7.6 Non-MOH Specialist Service At Health Clinic ...... 84
7.7 Supervisiory Visits ...... 85
7.8 Human Rights And Health Issues ...... 86
7.9 Primary Health Care Performance Initiative ...... 86
7.10 Asean Cluster 3 ...... 86
8 CHILD HEALTH SERVICES ...... 87
8.1 Attendance to Health Facilities ...... 87
8.2 G6PD Deficiency Screening Programme ...... 89
8.3 National Congenital Hypothyroidism Screening Programme ...... 90
8.4 National Quality Assurance Program for Neonatal Jaundice ...... 91
8.5 National Immunisation Programme Program ...... 92
8.6 Mortality Rates for Deaths Among Neonatal, Infant and Children Under 5 Years ...... 101
8.7 Child Health Sector: Activities in 2019 ...... 112
9 MATERNAL HEALTH CARE AND FAMILY PLANNING SERVICES ...... 117
9.1 Maternal Health Care ...... 117
9.2 Maternal Death ...... 123 3
9.3 Pre-Pregnancy Care ...... 126
9.4 Family Planning Programme ...... 127
9.5 Highlights ...... 129
10 SCHOOL HEALTH SERVICES ...... 130
10.1 School Health Services Coverage ...... 130
10.2 Morbidity Detected Among School Children ...... 131
10.3 School Health Service Immunization Coverage ...... 136
10.4 School Health Sector Meetings in 2019 ...... 138
10.5 School Health Service Monitoring Visit ...... 140
10.6 School Based Thalassemia Screening ...... 141
10.7 Thalassemia Carriers among the Form 4 Students in 2018 ...... 154
10.8 Monitoring Visits ...... 157
10.9 Thalassemia Control and Prevention Program Strategic Plan ...... 158
10.10 Thalassemia Control and Prevention Program Steering Committee Meeting ...... 158
11 ADOLESCENT HEALTH SERVICES ...... 159
11.1 Adolescent Health Services Coverage ...... 159
11.2 Sexual and Reproductive Health Services Coverage ...... 161
11.4 Common Causes of Morbidity in Adolescent...... 165
11.5 Adolescent Friendly Health Services Best Practice ...... 168
11.6 Networking with other Agencies and NGOs ...... 172
11.7 Human Resources and Training ...... 172
11.8 Way Forward ...... 176
12 ADULT HEALTH SERVICES ...... 176
12.1 Background ...... 176
12.2 Objectives...... 177
12.3 National Cervical Cancer Screening Programme ...... 177
12.4 The Way Forward in Cervical Cancer Prevention ...... 185
12.5 Breast Cancer Prevention Programme ...... 185
12.6 The Way Forward For Breast Cancer Prevention Programme ...... 191
12.7 Health Risk Screening Programme ...... 191
12.8 Activities and Achievement of Men’s Health Services ...... 196 4
13 HEALTH SERVICES FOR PERSONS WITH DISABILITIES (PWDs) ...... 200
13.1 Health Service for Children ...... 200
13.3 Health Service for Adult PWDs: Domiciliary Health Care Services (DHC) and Palliative Care in Primary Healthcare ...... 202
13.4 Health Services in the Community: Outreach Program to the Community-Based Rehabilitation Centre (CBR) ...... 205
13.5 Rehabilitation Services At Primary Health Care ...... 206
13.6 Data on Disability: National Health And Morbidity Survey (NHMS) ...... 221
14 ELDERLY HEALTHCARE SERVICES ...... 222
14.1 Introduction ...... 222
14.2 Elderly Health Care Programme Achievements ...... 223
14.3 Elderly Healthcare Training ...... 228
14.4 Main Focus in 2019 ...... 229
CONTRIBUTORS ...... 232
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1 PRIMARY MEDICAL CARE SECTOR The Primary Medical Care Sector is responsible for ensuring that the intervention services at the primary facilities are implemented in an integrated and quality manner, in collaboration with various sectors and other divisions within the Ministry of Health Malaysia.
1.1 Strengthening Preventive Activities In Health Clinics Integrated Health Risks Screening Integrated Health Risk Screening using the Health Status Screening Form (BSSK) was introduced in 2008, aimed at providing comprehensive health services and reducing disease burden through early detection of diseases to four (4) groups according to age group: adolescents (age 10 to 19), adult men and women (20 to 59 years old) and senior citizens (age 60 and older). In 2019, a total of 1,296,487 clients, which is 5.3 per cent of the estimated total population of 2019 by the age of 10, were screened. Majority of the people screened are Malay which is 69 per cent. Data shows that overweight issues are the highest risk among screened clients. Figure 1 Number and Percentage of Clients Screened By Age Group 2019
Source: Family Health Development Division
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Figure 2 Number And Percentage Of Clients Screened By Race 2019 80 70 60 50 40 30 20 10 0 898992 124790 68406 9012 88934 89650 13680 3023 Bumip Indige Bumip utera Foreig Malay China Indian nous utera Others Sarawa ner People Sabah k Percentage 69 10 5 1 7 7 1 0
Percentage
Source: BSSK Screening, Family Health Development Division, MOH, 2019
Figure 3 Number and percentage of Clients Screened With Health Risk, 2019
350000 297833 25.0% 23.0% 300000 20.0% 250000 200000 15.0% 140322 128060 150000 92863 58685 10.8% 80341 77747 10.0% 9.9% 73042 100000 70618 8.8% 7.2% 59724 6.2% 6.0% 19912 5.0% 50000 5.6% 5.4% 10584 4.6% 1.5% 0.8% 0 0.0%
Source: BSSK Screening, Family Health Development Division, MOH, 2019
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1.2 Health Risk Intervention Services Quit Smoking Services Quit Smoking Services began as early as 2000 at selected health clinics. The program is conducted in a team consisting of Medical Officers, Pharmacists and Paramedics. The National Strategic Plan Technical Meeting for Tobacco Control 2017 concluded that the target of quitting smoking was raised to 30 per cent and that the MPI calculation rate for Quit rate is from clients with Quit date. All health clinics must provide Quit Smoking Services and is equipped with equipment to carry out quit smoking activities. Healthcare staff at the Health Clinic need to receive training in the management of Quit Smoking Services. A total of 774 health clinics provided smoking cessation services. Quit rates for the Jan-June 2019 cohort showed an increment of 53.2 percent. For the Jan-June 2019 cohort, a total of 12,731 clients were registered. Among 3,893 clients who had 'Quit Date', 2,073 of them successfully quit smoking. The trends in smoking cessation are as shown in Figure 4.
Figure 4 Trend in Quit Rate, Year 2011 – 2018 (January -June)
Source: Stop Smoking Rate Data, Family of Health Development Division 2018
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1.3 Care of Patient Implementation of Wound Care Services at Health Clinics Wound care is one of the pre-existing services in the health clinic. The number of patients coming in for wound dressing is increasing and most cases are referred from the hospital. However, wound care in health clinics use conventional methods due to limitations in the infrastructure, equipment and skills of members. Quality and effective wound care is very important to ensure a speedy recovery. Inadequate and long-term wound care will expose patients to complications of infection. Conventional wound care using conventional methods is less effective and results in higher workloads as it requires daily wound cleaning. In line with the Director General of Health regarding the implementation of the Establishment of Wound Care Team at the Health Clinic the establishment of a primary care team at the primary health level should be implemented to improve overall wound care at all levels of health care. All MOH health clinics need to provide systematic, holistic quality wound care services to accelerate wound healing and reduce morbidity and mortality. The wound care service using the modern wound dressing method is being phased out starting in 2018 at health clinic with Family Health Specialist and expanded gradually. For the year 2019, training for wound care team from health clinics were conducted in 12 states were from Mac 2019 to August 2019. a) Status of Wound Care Program at Health Clinics Table 1 Health clinics with Wound Care Program Health Clinics with Health Clinics with Total Health Bil States wound care wound care District program (2018) program (2019)
1. Perlis 1 1 10
2. Kedah 11 39 22
3. Pulau Pinang 5 5 18
4. Perak 11 11 22
5. Selangor 9 20 18
6. W.Pkl&Putrajaya 5 33 37
7. Negeri Sembilan 7 11 18
8. Melaka 3 30 30
9. Johor 10 25 87
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10. Pahang 11 12 24
11. Terengganu 8 8 17
12. Kelantan 10 21 33
13. Sabah 26 13 7
14. Sarawak 40 24 24
15. W.P Labuan 1 1 1
GRAND TOTAL : 158 254 368
Source: Family of Health Development Division b) Number of Wound Care Cases The number of wound care cases for 2019 (Jul-Dec 2019) was 411,235 which included both 101,410 of new cases and 309,843 of follow up cases. The number of cases of wound care is the number of registered and receiving cases at the clinic. Figure 5 Number of Wound Care Treatment in Health Clinics by States 2019
NUMBER OF CASES OF WOUND DRESSING JUL - DEC 2019
60000
50000
40000
30000
TOTAL
20000
10000
0 PERLIS KEDAH P.PINANG PERAK SELANGOR WPKL N.SEMBILAN MELAKA JOHOR PAHANG TERENGGAN KELANTAN SARAWAK SABAH WP LABUAN U New Cases 1762 5616 6013 5587 9136 10172 6546 4968 17100 2904 2951 19623 4273 3936 823 Follow up Cases 13652 18900 16967 40805 30027 35408 27161 16596 50446 14253 7967 13603 11867 8727 3464
Sumber: Data Perkhidmatan Penjagaan Luka, Bahagian Pembangunan Kesihatan Kelurga 201
New Cases of Wound Care Treatment at a Health Clinics Number of new cases are referral cases from hospitals, other Health clinics and other cases that come to the clinic (walk-ins, referrals from community clinics, etc). For the year 2019 (July-Dec 2019), total number of new cases referred from hospitals were 40,023, referred from other Health Clinics were 27,175 and 34,212 were from wound care clinics cases.
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Figure 6 Number of New Cases by States, 2019
NUMBER OF NEW CASES OF WOUND DRESSING JUL - DEC 2019
10000
9000
8000
7000 6000
5000 TOTAL 4000 3000
2000
1000
0 PERL KEDA P.PIN PERA SELA WPK N.SE MELA JOHO PAHA TERE KELA SARA SABA WP IS H ANG K NGO L MBIL KA R NG NGG NTAN WAK H LABU R AN ANU AN (i) Hospital 1196 2768 3190 1770 2993 4978 2741 2652 7831 1086 1636 3424 1638 1850 270 (ii) Klinik Kesihatan 99 1089 666 2428 2529 3331 1182 377 7042 341 289 6384 533 544 341 (iii) Others 467 1759 2157 1389 3614 1863 2623 1939 2227 1477 1026 9815 2102 1542 212
Sourrce: Family of Health Development Division
Types of Wound For the year 2019, 65 per cent of wound care dressing in health clinics uses modern wound dressing and 35 per cent uses conventional method. The top three common type of wound were diabetes ulcer (33 per cent), surgical cases (24 per cent) and post-traumatic cases (21 per cent). Figure 7 Types of Wound
Source: Family Health Development Division
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Pain Free Program in Health Clinics Pain Free Program was introduced in 2008 to be implemented in MOH hospitals. It is based on multi-disciplinary approach for treating patient in pain. In late 2017, this program is expanded to include other health facilities including health clinics. with the directive of the Director General of Health on Strengthening and Extending the Scope of Pain as 5th Vital Sign and Pain Free Program for the Ministry of Health Malaysia facilities.
Status of Implementation of Pain as Fifth Vital Sign (P5VS) in Health Clinic The implementation of pain free program in health clinics comprises of two main scopes which is implementation of Pain as Fifth Vital Sign (P5VS) and strengthening of pain management. The implementation of P5VS begins with one health clinic per district initially and in 2018, a total of 164 health clinics started this program. In 2019, the program expanded to involve 269 health clinics. Health personnel at the health clinic were trained to facilitate the implementation. Garis panduan pelaksanaan tahap kesakitan sebagai tanda vital kelima (P5VS) dan pengurusan kesakitan di klinik kesihatan dan pain ruler telah di edar kepada semua negeri pada tahun 2018 untuk kegunaan klinik kesihatan Guideline on implementation of Pain as Fifth Vital Sign (P5VS) and management of pain at health clinic, and pain ruler were distributed in 2018 to all states.
Table 2 Number of Health Clinics Implementing Pain as Fifth Vital Sign, 2019 No. STATESI No. of District No. of Health No. of Health Clinics Health Office Clinics with P5VS Program
1 PERLIS 1 10 10
2 KEDAH 11 61 22
3 PULAU PINANG 5 30 5
4 PERAK 11 87 26
5 SELANGOR 9 79 9
6 W.P KL & PUTRAJAYA 5 19 17
7 NEGERI SEMBILAN 7 50 17
8 MELAKA 3 30 3
9 JOHOR 10 96 10
10 PAHANG 11 86 49
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11 TERENGGANU 8 52 52
12 KELANTAN 10 91 27
13 SABAH 26 109 12
14 SARAWAK 40 211 9
15 W.P LABUAN 1 2 1
TOTAL 158 1013 269
Picture 1: Pain Ruler
Source: Family of Health Development Division
Hepatitis C Screening Services at the Health Clinic Management of Hepatitis C has been practiced in hospitals and now being expanded to health clinics in 2019 to facilitate the process of screening and treatment for hepatitis C cases nearer to the community. Only those with non-cirrhotic hepatitis C will be treated at health clinics. Those with cirrhotic liver or other complications will be referred and treated in hospitals. Direct Acting Antiviral (DAAs) drugs were made available to the health clinics. The expansion of screening and treatment for Hepatitis C cases for health clinics is carried out in phases, started in ealy 2019 and involved 25 health clinics.
1.4 Treatment of Chronic Disease Complications Chronic Kidney Disease Management Services Chronic Kidney Disease (CKD) Health Care Services is one of the specific activities proposed for the Public Health Program to support the National Action Plan for Healthy Kidneys (ACT-KID) 2018-2025. To make this program successful, a framework including a clearer visit process and the development of a logbook for training of medical personnel was developed. The implementation of this program is a collaboration between the National Nephrology Service, Family Medical Services and the Family Health Development Division led by the Disease Control Division.
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Hemodialysis Services in Health Clinics Hemodialysis services at health clinics are an extension of dialysis services to nearby hospitals. Although this service is available in hospitals, it is also required at the community level especially for areas located away from hospitals or private dialysis centers. With the availability of hemodialysis services in health clinics, it can expand access to kidney failure patients especially in rural areas far away from the facilities that provide these services.
Haemodialysis services began at selected health clinics in 2013. As of 2019, there are 16 health clinics providing hemodialysis services. Table 3 Health Clinic with Hemodialysis Services Operational Year Health Clinics
2013 KK Simpang Renggam, Kluang Johor KK Kodiang, Kubang Pasu Kedah 2014 KK Song, Song Sarawak KK Mahligai Bachok, Kota Bharu Kelantan KK Sg Lembing, Kuantan Pahang 2015 KK Debak, Betong Sarawak Klinik Kesihatan Batu Niah, Miri Sarawak 2016 Klinik Kesihatan Tatau, Bintulu, Sarawak Klinik Kesihatan Bestari Jaya, Kuala Selangor, Selangor Klinik Kesihatan Bandar Mas, Kota Tinggi , Johor Klinik Kesihatan Chiku 3, Gua Musang Kelantan 2017 KK Lenggong, Gerik Perak 2018 KK Kemahang, Kelantan 2019 KK Sungai Koyan, Pahang KK Cheng Melaka KK Nabawan, Sabah Source: Family of Health Development Division
Mental Health Services in Primary Care (Health Clinics) Mental health is an essential component of health and mental health services had been integrated into primary health care services since late 1990s. Services include promotion of well-being, prevention of mental disorders, mental health screening, treatment and rehabilitation of people affected by mental disorders.
Promotional activities had been carried out as part of the Healthy Lifestyle Campaign. Screening for mental health disorders had been carried out as part of the integrated health screening in the health clinics, using a standardized screening form, BSSK (Borang Saringan Status 14
Kesihatan), for adolescent, adult and elderly. Healthy Mind Services are also being carried in health clinics to screen for stress, anxiety and depression. Fifteen (15) health clinics provided psychosocial rehabilitation for people affected by mental disorders.
a) Mental Health Screening using BSSK and DASS Screening For the year 2019, a total of 1,296,487 of outpatient attendance had been screened for risk of mental health problems using the BSSK screening format. Out of this, 9,318 (0.7 per cent) were identified to have risk of mental health problems . The adolescent had the highest proportion of those detected at risk for mental health problems. Table 4 Number of People Screened and Percentage of Mental Health Risks by Age Group, 2019 Age Group Number Screened Number with Percentage Mental Health Risks
Adolescent 323794 4723 1.5%
Adult (Male) 368101 1544 0.4%
Adult (Female) 391106 1973 0.5%
Elderly 213486 1078 0.5%
TOTAL 1296487 9318 0.7%
Source: BSSK Screening, Family Health Development Division, MOH.
A total of 358,174 have been screened using DASS (Depression Anxiety Stress Scales). Out of this, 25,333 (7.1 per cent) have stress 33,694 (9.4 per cent) have anxiety, and 21,158 (5.9 per cent) have depression.
b) Treatment of Stable Mental Health Patients in Health Clinics For the year 2019, a total of 23521 cases received treatment at health clinics. Out of this, 10.5 per cent (2464) were new cases. Stable cases that were on follow-up in health clinics were given pharmacological treatment, counseling and in selected health clinics, psychosocial rehabilitation. Their compliance to treatment was monitored to prevent relapses and in 2019, the defaulter rate of 7.3 per cent (1712 cases) was noted, within the WHO standard of not more than 10 per cent.
1.5 Klinik Komuniti The year 2019 saw the enhancement of services provided at Klinik Komuniti in line with Pelan Transformasi Perkhidmatan Klinik 1Malaysia (Klinik1Malaysia Services Transformation Plan). With the changing scope of services now focusing on outpatient treatment and especially 15
chronic non-communicable diseases (Chronic NCD), the Ministry has upgraded 27 Klinik 1 Malaysia with maternal and child health services into Klinik Kesihatan. In addition, a total of 38 non-cost-effective facilities have been closed. This brings the total number of Klinik Komuniti to 281 by December 2019. Medical Officer (Doctors) coverage increased from 26.9 percent in 2018 (93 out of 346 facilities) to 46.6 percent in December 2019 (131 out of 281 facilities). Of these, 105 Community Clinics had permanent Medical Officers, while the rest were on scheduled visits. The placement of 50 Pharmacy Officers is also being implemented in 2019. Moving ahead, the Ministry has approved posts for Medical Officer for all 281 Community Clinics and the filling of posts will take place over the course of 2019 to 2020. Table 5 Klinik Komuniti Distribution until December 2019 State Number of KKOM KKOM with Dr Perlis 1 0 Kedah 21 5 Pulau Pinang 10 4 Perak 22 11 Selangor 40 5 Kuala Lumpur 22 22 Negeri Sembilan 16 7 Melaka 18 1 Johor 32 13 Pahang 13 4 Terengganu 14 4 Kelantan 10 9 Sarawak 29 20 Sabah 32 25 Labuan 1 1 JUMLAH 281 131 Source: Family of Health Development Division
For 2019, there was a 14 per cent decrease in patient attendance from 5.88 million in 2018, to 5.07 million following a reduction in total number of facilities from 346 in 2018 to 281 in 2019:
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Figure 8 Patient Attendance Trend to K1M / KKOM 2010 – 2019
Source: BSSK Screening, Family Health Development Division, MOH.
Figure 9 Patient Attendance 2019 Distribution by State
Source: BSSK Screening, Family Health Development Division, MOH. 17
2 PRIMARY HEALTH FACILITY INFRASTRUCTURE DEVELOPMENT SECTOR
2.1 Primary Health Care Facilities Static primary health care facilities are categorised into health clinics, maternal and child health clinics, rural health clinics and community clinics (KKOM) previously known as 1Malaysia clinics. In 2019, there were a total of 3166 static clinics. The number of static primary health care facilities by state and category are as in Table 6. Table 6 Number of Static Primary Health Care Facilities by State and Category, 2018 and 2019 MATERNAL RURAL COMMUNITY HEALTH AND CHILD NUMBER HEALTH CLINICS TOTAL CLINICS HEALTH NO. STATES OF CLINICS (KKOM) DISTRICTS CLINICS 2018 2019 2018 2019 2018 2019 2018 2019 2018 2019
1 Perlis 1 10 10 0 0 30 30 4 1 44 41
2 Kedah 11 60 61 6 6 218 217 22 20 306 304
3 P. Pinang 5 30 30 6 6 59 59 24 10 119 105
4 Perak 11 87 87 11 11 231 231 24 21 353 350
5 Selangor 9 79 80 4 4 113 112 48 39 244 235
W.P Kuala 6 Lumpur & 5 19 19 7 6 0 0 26 22 52 47 Putrajaya
7 N. Sembilan 7 50 50 0 0 96 96 18 16 164 162
8 Melaka 3 30 32 1 0 60 60 19 18 110 110
9 Johor 10 96 96 3 3 261 261 35 31 395 391
10 Pahang 11 86 86 5 4 239 238 20 13 350 341
11 Terengganu 8 47 50 1 1 128 125 15 14 191 190
12 Kelantan 10 85 89 0 0 175 174 21 10 281 273
13 Sabah 26 109 109 22 22 166 166 36 31 333 328
14 Sarawak 40 210 215 24 25 5 4 34 32 274 276
15 W.P Labuan 1 2 2 0 0 10 10 1 1 13 13
TOTAL 158 1000 1016 90 88 1791 1783 347 279 3229 3166
Source: Family Health Development Division
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Total number of health clinics has increased from 1000 in 2018 to 1016 in 2019. The increase was contributed by three (3) new health clinics and upgrading of one (1) maternal and child health clinics, four (4) rural health clinics and eight (8) community clinics (KKOM) to health clinics. The number of maternal and child health clinics have reduced from 90 (2018) to 88 (2019) as one (1) were upgraded to health clinics and two (2) were closed. In 2019, the number of rural health clinics has reduced to 1783 due to four (4) were upgraded to health clinics and one (1) to maternal and child health clinics and three (3) were closed.
2.2 Standard Design And One Off Design Clinics The standard design for each type of clinics has been developed. The available standard design clinics are type 2 to type 7. These standard designs will facilitate and assist state health department for the planning of the new clinics under each Rolling Plan. The type 2 Standard Design consist two (2) categories, the compact high rise design to accommodate for the smaller land area (1-2 acres) and the 2 storey standard design, if the land area is bigger (2-3 acres). The type 7 Standard Design however have 3 designs: a) On stilt with 4 units of Quarters b) On ground with 4 units of Quarters c) On ground with Alternate Birthing Centre and observation ward (optional). For this design, the quarters will be built separately according to the number of units required. Table 7 Number of Clinics with Standard and One-Off Design by States, 2019 CLINICS WITH STANDARD DESIGN NO. STATES ONE-OFF 2 3 4 5 6 7 1 Perlis 0 1 0 0 0 0 0 2 Kedah 0 0 9 0 0 0 0 3 Pulau Pinang 1 1 8 0 0 0 0 4 Perak 0 3 9 2 0 0 0 5 Selangor 0 1 18 0 0 0 1 W.P Kuala Lumpur 6 3 1 1 0 0 0 0 & Putrajaya 7 Negeri Sembilan 0 3 16 0 0 0 0 8 Melaka 0 1 9 0 0 0 0 9 Johor 1 2 19 0 0 1 0 10 Pahang 0 1 12 0 0 0 0 11 Terengganu 0 0 10 0 1 0 0 12 Kelantan 0 1 5 0 0 2 0 13 Sabah 0 3 4 5 0 4 0 14 Sarawak 0 1 10 6 8 0 0 15 W.P. Labuan 0 0 1 0 0 0 0 5 19 131 13 9 7 1 TOTAL 185 Source: Family of Health Development Division
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2.3 Planning For Building Of New Primary Health Care Facility Under Eleventh Malaysia Plan Rolling Plan 4 (RMK 11 – RP4) 2019
Due to identified reasons, the committee has agreed that no new project for clinics was approved under Rolling Plan 4 (2019).
2.4 Clinic Support Services [Perkhidmatan Sokongan Klinik (PSK)] Clinic Support Services is an initiative in outsourcing the maintenance of health clinics, started in July 2015. The scope of services involved in this PSK are Facility Engineering Maintenance Services (FEMS), Cleansing Services (CLS) and Clinical Waste Management Services (CWMS). Currently 173 health clinics were selected to receive these services. The health clinics selected based are based on criteria follows: a) Standard Clinics with Standard Design b) Clinics that have comprehensive and complex engineering system of centralised air conditioning c) High daily workload (Classified by average daily attendees Type 1-Type 4) One company was awarded to only one state to provide services delivery of PSK. Department of Engineering Services, Ministry of Health prepared the technical specification document and the State Health Department does the tendering process individually. The Privatisation and Procurement Division, Ministry of Health will then proceed the evaluation and assessment and finally the tendering award. The number of health clinics involved in the PSK by states are as in Table 8. Table 8 Number of Clinics Involved With PSK and Company Awarded by States, 2019 Number of No. State Company Health Clinics
1 Perlis 2 Warisan Business Solution Sdn Bhd
2 Kedah 12 Paradigm Energy Sdn Bhd
3 Pulau Pinang 9 Edgenta Healthronics Sdn Bhd
4 Perak 14 Teeraz Niaga Sdn Bhd
5 Selangor 21 Produktif Kualiti Medical Supply Sdn Bhd
6 W.P. Kuala Lumpur and Putrajaya 7 Global View Engineering Sdn Bhd
7 Negeri Sembilan 13 RND Resources Sdn Bhd
8 Melaka 8 NMH Engineering Sdn Bhd
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9 Johor 16 Jana Tanmia Resources Sdn Bhd
10 Pahang 13 Mazateknik Sdn Bhd
11 Terengganu 10 Abad Kenanga Sdn Bhd
12 Kelantan 7 Total IFM Sdn Bhd
13 Sabah 20 Jawat Johan Sdn Bhd
14 Sarawak 21 ADL Medical System Sdn Bhd
TOTAL 173
Source: Family Health Development Division
2.5 PSK Audit Visit And Project Committee Meeting Pre-audit visit has been conducted at KK Bandar Air Itam and KK Butterworth and two (2) Project Committee Meetings were carried out in Penang Health State Department. These activity were carried out with Department of Engineering Services
2.6 Feedback, Comments, Suggestions, Recommendations And Approval This sector is responsible in providing feedback, comments, suggestions, approval, recommendations witch are related infrastructure, and non-medical equipment requested by the state health department and varies agencies. In 2019, 119 actions were taken.
Table 9 Number of Responses by Categories NO. ITEMS TOTAL
1 Request for new and upgrading primary health facilities projects 30
2 Land acquisition and land tittle related to primary health facilities 27
3 Allocation/financial related to primary health facilities 20
4 Others (complaints, closure of the facilities, facility registry) 42 TOTAL 119
Source: Family Health Development Division
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2.7 Visits To Health Clinics Visits to health clinics were carried out in 2019 as in table below. Table 10 Visits to Health Clinics for Various Reasons NO. HEALTH CLINICS DETAILS
1 KK Bayu Damai, Johor Monitoring of upgrading of KD to KK
2 KK Sg Rengit, Johor Observe the A & E special service
3 KK Pasir Gajah, Terengganu Visit by the Director of FHDD upon the 4 KK Seberang Tayor, operations of the new KK 7 standard design Terengganu
5 KK Rantau Panjang, Kelantan Project Monitoring Visit
6 KD Terisu, Pahang Field visit by YBMK to the orang Asli clinics 7 KK Kg Raja, Pahang
8 KK Gombak Setia, Selangor Operations of new health clinic with compact/high rise design
9 KK Puchong, Selangor Operations of new type 3 health clinic
10 KK Siburan, Sarawak Official visit by YBMK for ground breaking Ceremony
11 KK Sg Asap, Sarawak Visit to see the appropriateness and suitability of building new clinic (KK Bakun to 12 KK Sarawak Hidro, Sarawak replace KK Sarawak HIdro)
13 KK Trusan, Sarawak Official Visit by YBMK
14 KD Senai, Johor To evaluate the appropriateness and suitability of upgrading to health clinic. 15 KKOM Senai, Johor
Source: Family of Health Development Division
3 PRIMARY HEALTH CARE INFORMATICS SECTOR
3.1 Teleprimary Care (TPC) Teleprimary Care (TPC) is a Health Information System that connects primary and secondary healthcare facilities. The backbone for this system is the TPC application developed by the Ministry of Health Malaysia. The application caters to patient care from registration, consultation, order management, referral and allocation of follow-up appointment at the 22
ambulatory care setting. Since 2005, TPC is being used in 89 primary health care facilities and specialist outpatient clinics in 6 hospitals. This accounts for only 9 per cent of primary care facilities. TPC will be migrated to Teleprimary Care-Oral Health Clinical Information System (TPC-OHCIS) in phases starting from 2020 onwards.
Activity / Achievement The Teleprimary Care (TPC) legacy system migration project at 89 health clinics to the improved system, the Teleprimary Care-Oral Health Clinical Information System (TPC-OHCIS), will be implemented by 2020. It aims to replace the legacy system that has been in use since 2005. The project involves health clinics in seven (7) states namely Perlis, Selangor, WPKL and Putrajaya, Johor, Pahang, Sabah and Sarawak. The key focuses of the TPC sector for 2019 were: a) Migration of TPC system to TPC-OHCIS (planning and preparation of tender documents) b) TPC and TPC-OHCIS System Monitoring (maintenance of the system) c) Change management setup and TOT for TPC system migration to TPC-OHCIS d) Monitoring the utilization of TPC and TPC-OHCIS system in the clinic to ensure optimum usage by users
Picture 2 System Migration from TPC to TPC-OHCIS Preparation Meeting for States from 21 to 22 August 2019 and 17 to 18 September 2019
Source: TPC FB Page Picture 3 Briefing On TPC-OHCIS System Installation to ICT Officers of Perlis State Health Department on October 22, 2019
Source: TPC FB Page
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Picture 4 Training of Core Trainers in Perlis State Health Department from 23 to 25 October 2019
Source: TPC FB Page
Picture 5 TPC-OHCIS Briefing Session to Melaka State Health Department on 5 November 2019
Source: TPC FB Page
Picture 6 Training Session with MIMOS for JSON File Usage on 5 November 2019
Source: TPC FB Page
Picture 7 TPC-OHCIS Booth Exhibition for ASEAN Health Summit and Exhibition 2019 at Miti Tower, Kuala Lumpur on November 20 and 21, 2019
Source: TPC FB Page
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Picture 8 Public Sector Initiatives Exhibition at ASEAN-ROK Summit and Exhibition 2019 in Busan, Korea on November 25 and 26 2019
Source: TPC FB Page
3.2 Teleprimary Care (TPC) Since 2005, TPC is being used in 89 primary health care facilities and specialist outpatient clinics in 6 hospitals. This accounts for only 9% of primary care facilities. TPC will be migrated to Teleprimary Care- Oral Health Clinical Information System (TPC-OHCIS) in phases starting from 2020 onwards.
Table 11 Total Number of New Patients Registered, Total Number of Patient’s Visits and Total Number of Medical Records (Careplan) from 2010 until 2019
Year Transaction Type
Total no. of new Total no. of visits Total no. of medical patients registered records (Careplan)
2019 612,397 8,551,562 6,812,835
2018 648,203 6,959,285 4,815,177
2017 665,065 8,538,313 4,495,770
2016 633,410 6,638,760 5,689,326
2015 540,947 6,925,753 3,290,237
2014 708,487 7,224,046 2,474,012
2013 685,399 660,6017 2,332,243
2012 749,116 635,6628 2,043,262
2011 860,415 611,5264 1,390, 212
2010 808,785 470,2686 881,162
Note: Data source acquired as input by healthcare providers from TPC database.
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3.3 Teleprimary Care-Oral Health Clinical Information System (TPC-OHCIS) The decision to assimilate the two existing systems of TPC and OHCIS resulted in a collaborative project between MOH and MIMOS which kicked off in December 2014. The project was funded by a research grant allocated by MOSTI. By middle of 2016 the development phase was completed. The application subsequently underwent a few cycles of vigorous user acceptance testing. Activities of Provisional and Final Acceptance Tests were completed in the first half of 2017. The new system is currently piloted at six (6) Health Clinics in Seremban district, Negeri Sembilan. In 2019, the total number of newly registered patients were 61,303 patients, while total number of visits were 837,715 visits.
Figure 12 Total Number of Newly Registered Patients and Total Number of Patient Visits in TPC-OHCIS System from 2018 until 2019
Source: Data source acquired as input by healthcare providers from TPC-OHCIS database.
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Figure 13 Total Number of Newly Registered Patients and Total Number of Patient Visits in TPC-OHCIS System by Clinics from 2018 until 2019
Note: Data source acquired as input by healthcare providers from TPC-OHCIS database.
4 CLINICAL AND TECHNICAL SUPPORT SERVICES SECTOR
4.1 Human Resource Development in Primary Health Care Since 2014, the human resource development in primary care has been very limited due to unavailability of new posts. However, continuous efforts have been made through trade off mechanism, redeployment and multitasking to further enhance human resource capacity in all primary care facilities nationwide. The percentage of posts filled by healthcare professionals in health clinics increased slightly compared to 2018 as shown in Table 12. But, this number was still inadequate to address the population health needs in primary care. Based on the existing posts, the percentage of post filled was more than 90% in most of the categories. The Continuous Professional Development (CPD) was further enhanced through the introduction of a new degree program for public health nursing and formalization of a parallel pathway training program for Family Medicine Specialist.
The year 2019 marks a shift in the family medicine specialty with the addition of another parallel pathway training program which has been recognized by the Ministry of Health Malaysia namely Malaysia Ireland Training of Family Medicine (MInTFM). It is run by the Royal 27
College of Surgeons Ireland and University College Dublin Malaysia Campus (RUMC); in collaboration with The Irish College of General Practitioners (ICGP); and Iheed Health Training Limited. This provides more option or opportunity for medical doctors who are interested to pursue their career in family medicine. A total of 34 medical officers had already enrolled in this training program. Table 12 Status of post filled by category (2015-2019) No Category Year
2105 2016 2017 2018 2019
1 Family Medicine 281 329 395 439 520 Specialist (124.0%) (107.0%) (129.0%) (142.0%) (169.0%)
2 Medical and Health 3643 4929 4689 5877 6862 Officer (98.5%) (110.0%) (119.9%) (101.0%) (91.6%)
3 Pharmacist 1846 2149 2142 2122 2174 (84.8%) (98.9%) (97.8%) (96.7%) (96.8%)
4 Pharmacist Assistant 1950 2016 1991 1890 2004 (95.0%) (98.3%) (96.7%) (88.5%) (97.3%)
5 Assistant Medical Officer 4294 4374 5045 5270 5354 (90.0%) (92.0%) (96.0%) (95.1%) (95.8%)
6 Nurse 10,943 11,122 11,752 11,752 11,644 (87.4%) (94.0%) (98.1%) (98.1%) (98.1%)
7 Community Health Nurse 13,837 13,853 13,331 13,331 13,414 (90.8%) (97.2%) (93.59%) (93.59%) (92.6%)
8 Medical Lab Technologist 1,856 1,896 1,883 1,916 2,068 (92.4%) (92.9%) (94.0%) (96.2%) (97.1%)
9 Radiographer 410 399 402 410 416 (95.3%) (92.79%) (99.75%) (92.3%) (94.3%)
10 Medical Social Worker* 20 20 19 21 21 (95.2%) (95.2%) (85.71%) (99.0%) (99.0%)
11 Physiotherapist* 308 332 242 337 343 (86.8%)
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(93.0%) (96.0%) (94.1%) (95.5%)
12 Occupational Therapist* 215 215 242 258 256 (81.4%) (81.4%) (96.03%) (97.7%) (96.9%)
13 Dietitian* 60 59 63 66 64 (92.0%) (91.0%) (95.5%) (100%) (95.5%)
14 Optometrist* 1 1 2 2 2 (100%) (100%) (100%) (100%) (100%)
*Additional category has been monitored under Primary Care since 2015.
Source: Family Health Development Division, MOH
4.2 Radiology Service By the end of 2019, there were 220 health clinics across Malaysia providing radiological service. This represents an increase of 3.29 percent compared to 213 health clinics in 2018. The radiology service in health clinics was mainly the General Radiography Examination which includes chest X-Ray, abdomen X-Ray, skull X-Ray, spine X-Ray, extremities X-Ray and other parts of human body. Kuala Lumpur Health Clinic (KKKL) was the only health clinic providing two (2) more additional modalities, Orthopantomography (OPG) and Bone Densitometry. The health clinics with radiology service were located both in urban and rural areas whereby 153 (69.55 per cent)were in urban and 67 (30.45 per cent) were in rural as shown in Table 13. Table 13 Distribution of Health Clinics with Radiology Service by State 2019. No. State No of District Urban Rural Total Health Clinic
1 Perlis 1 1 0 1
2 Kedah 11 15 2 17
3 P.Pinang 5 8 3 11
4 Perak 11 27 1 24
5 Selangor 9 25 2 27
6 WP K.L & Putrajaya 5 6 0 6
7 N.Sembilan 7 9 8 17
8 Melaka 3 9 4 13
9 Johor 10 13 12 25
10 Pahang 11 13 5 18
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11 Terengganu 8 7 6 13
12 Kelantan 10 4 11 15
13 Sabah 26 6 3 9
14 Sarawak 40 13 10 23
15 Wilayah P. Labuan 1 1 0 1
Total 158 153 67 220
Source: Family Health Development Division, MOH For many years, General Radiography Examination with a Conventional Radiography System has been used in health clinics which requires film processing in the dark room. Gradually, the conventional system has been upgraded to Computed Radiographic (CR) system in line with the advancement in diagnostic imaging technology. The replacement process was carried out in stages whereby priority was to replace the machine that had been declared Beyond Economical Repaired (BER). The number of health clinics with the CR system increased nearly 62% from only 55 in 2018 to 84 health clinics in 2019 (as in table 2.2). In addition, several health clinics were also installed with Picture Archiving Communication System (PACS). Up to December 2019,only 18 health clinics were operated with the PACS system as shown in Table 14.
Table 14 Number of Facilities with Conventional Systems, CR Systems and Mini PACS (2016-2019) System
Conventional Computered Computered Total System Radiography Radiography System Year System with PACS
2016 154 41 7 195
2017 163 49 8 212
2018 158 55 10 213
2019 136 84 18 220
Source: Family Health Development Division, MOH
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Table 15 List of Health Clinics with PACS System No. State District Health Clinic (HC) Type of Health Clinic
1 Terengganu Kuala Terengganu Hiliran Type 2
2 Terengganu Marang Bukit Payung Type 2
3 Terengganu Dungun Kuala Dungun Type 3
4 Terengganu Dungun Ketengah Jaya Type 4
5 Terengganu Setiu Permaisuri Type 4
6 Terengganu Setiu Rahmat Type 4
7 Terengganu Hulu Terenggganu Kuala Berang Type 3
8 Terengganu Marang Marang Type 3
9 Terengganu Besut Padang Luas Type 3
10 Terengganu Kemaman Batu 2 1/2 Type 3
11 Terengganu Kuala Terengganu Manir Type 3
12 Terengganu Kuala Terengganu Chendering Type 7
13 Pahang Maran Maran Type 4
14 Pahang Bera Padang Luas Type 4
15 Pahang Bentong Karak Type 4
16 Sabah Telupid Telupid Type 4
17 Selangor Gombak Gombak Setia Type 1
18 Federal Territory of Kuala Lumpur Kuala Lumpur Type 1 KL
Source: Family Health Development Division, MOH In general, the workload for radiology services had increased over the past few years. The highest workload was seen in Sarawak, followed by Johor and Perak. The total number of radiological examination increased by 3.4 percent for 2019 (1,129,639 cases) as compared to 2018 (1,092,028 cases). However, it was noted that the workload for the Federal Territory of Labuan and Putrajaya and Perak were reduced. The major contributing factor was due to the several non-functioning X-Ray equipment in the respective states.
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Table 16 Workload of the Radiology Services in Health Clinics 2015 – 2019 Year
State 2015 2016 2017 2018 2019 Perlis 4,459 7,938 7,852 9,782 9,864
Kedah 57,813 70,221 85,101 95,868 97,277
Pulau Pinang 30,274 35,981 33,586 39,251 41,171
Perak 100,182 103,179 102,269 104,639 101,538
Selangor 87,032 79,238 72,238 90,135 89,805
WP KL & Putrajaya 27,587 28,596 39,753 56,982 56,824
N. Sembilan 56,168 60,932 62,248 65,054 66,090
Melaka 33,114 38,902 48,968 53,725 56,110
Johor 123,676 129,789 131,190 128,942 137,108
Pahang 49,582 53,251 70,432 70,159 71,424
Terengganu 39,112 45,282 57,062 58,893 64,269
Kelantan 54,708 62,721 64,372 73,945 76,509
Sabah 41,853 50,662 52,510 82,702 92,476
Sarawak 88,789 122,182 125,422 154,765 163,624
WP Labuan 3,257 3,965 4,507 7,186 5,550
Jumlah 797,606 892,750 958,230 1,092,028 1,129,639
Source: Family Health Development Division, MOH Two indicators were used to monitor the quality assurance program (QAP) for radiological services i.e the percentage of film rejections for conventional system processing not exceeding 2.5 per cent and retake of digital image not exceeding 2.5 per cent. The percentage of both indicators were lower for 2019 compared to 2018 as shown in the table 17.
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Table 17 QAP for Radiology Services in Primary Care (2016-2019) Parameter Year (Standard <2.5%)
2016 2017 2018 2019
Total number of Health Clinic involved 195 212 213 220
Total Health Clinic Reached Standard 193/195 212/212 213/213 220/220 (98.97%) (100%) (100%) (100%)
Total percentage of rejected films 0.84% 0.83% 0.74% 0.66% (conventional processing)
Total percentage Retake of Digital Image None None 0.53% 0.48% ( CR System)
Source: Family Health Development Division, MOH
QAP Acheivement All states were able to meet the standard of less than 2.5 percent for the percentage of rejections of X-Ray films using the conventional system as shown in Table 18. Perlis has only one health clinic providing radiological services and fully used the CR system.
Table 18 Percentage Rejected of X-Ray Films Using Conventional System 2019. NO. STATE TOTAL REJECTED TOTAL FILMS STANDARD FILMS <2.5%
1 Perlis NR NR NR
2 Kedah 98,770 0.68% 0.68%
3 Pulau Pinang 44,059 0.34% 0.34%
4 Perak 91,477 0.67% 0.67%
5 Selangor 71,641 1.13% 1.14%
6 Federal Territory of KL & Putrajaya 8,870 0.75% 0.75%
7 Negeri Sembilan 22,923 0.92% 0.92%
8 Melaka 51,427 0.56% 0.56%
9 Johor 113,157 0.84% 0.84%
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10 Pahang 66,473 0.28% 0.28%
11 Terengganu 17,003 0.32% 0.32%
12 Kelantan 21,086 0.67% 0.67%
13 Sabah 58,070 0.56% 0.56%
14 Sarawak 162,212 0.63% 0.63%
15 Federal Territory of Labuan 5,976 0.75% 0.75%
Total 5,534 833,144 0.66%
Source: Family Health Development Division, MOH For the retake of digital image, Melaka has shown the lowest percentage followed by Penang and Negeri Sembilan (refer Table 19). The Federal Territory of Labuan has only one health clinic with radiology services and used conventional film processing .
Table 19 Percentage Retake of Digital Image 2019 NO STATE TOTAL RETAKE TOTAL NUMBER STANDARD OF DIGITAL OF DIGITAL <2.5% IMAGES IMAGES
1 Perlis 40 11,471 0.35%
2 Kedah 152 14,793 1.03%
3 Pulau Pinang 5 2,109 0.24%
4 Perak 72 16,378 0.44%
5 Selangor 282 33,869 0.83%
6 Federal Territory of KL & 394 53,468 0.74% Putrajaya
7 WP Putrajaya 37 15,720 0.24%
8 Melaka 25 11,876 0.21%
9 Negeri Sembilan 122 50,584 0.24%
10 Johor 197 41,253 0.48%
11 Pahang 61 11,150 0.55%
12 Terengganu 233 61,157 0.38%
13 Kelantan 207 66,615 0.31%
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14 Sabah 176 37,582 0.47%
15 Sarawak 67 8,559 0.78%
16 WP Labuan NR NR NR
Total 2035 420,864 0.48%
Source: Family Health Development Division, MOH
4.3 Laboratory services There are 754 laboratories in primary health care, with is an increase of 2.4 per cent from 736 laboratories in 2018 as seen in Figure 14. Meanwhile, the number of Medical Laboratory Technologist increased 7.9 per cent to 2,068 in 2019, as compared to 1,916 in the previous year. This increase was mostly due to the inclusion of all medical laboratory technologists working in primary care laboratories. Previously, only medical laboratory technologists working under activity 2.212 were calculated. The workload for the past two years showed an increasing trend from 88,618,397 in 2018 to 95,077, 356 in 2019 as presented in Figure 15 and Figure 16. This is an increase of 7.3 per cent. The workload was correlated to the types of clinic in each state as seen in Figure 17 and Figure 18. The workload was higher in the states with more type one (1) clinic as compared with states with other types of clinics. For example, Selangor has the most number of type one (1), hence the workload is the highest. The decrease in workload in 2017 was due to changes in workload calculation introduced by the National Pathology Services. Figure 14 Number of Facilities with laboratories by state in 2019
Source: Family Health Development Division
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Figure 15 Total Workload of Primary Care Laboratories for 2016-2019
Source: Family Health Development Division
Figure 16 Workload for Laboratories in Primary Care by State (2017 - 2019)
16,000,000 14,000,000
12,000,000 10,000,000
testsNoof 8,000,000 6,000,000
4,000,000 2,000,000 0 SELA N.SE WP PERLI KEDA P.PIN PERA WPK MEL JOHO PAHA TRG SARA SABA NGO MBIL KLTN LABU S H ANG K L&P AKA R NG N WAK H R AN AN 2017 943,4 9,251 3,556 9,218 10,82 2,269 4,391 3,474 8,280 5,189 2,185 5,006 5,483 4,992 216,1 2018 1,208 8,910 4,085 7,888 13,31 3,248 4,744 4,128 10,64 5,727 5,152 5,367 7,344 6,652 202,6 2019 1,355 9,610 3,945 8,015 15,12 3,515 5,565 4,543 10,05 6,332 5,520 6,530 7,457 7,033 470,6 NEGERI-NEGERI 2017 2018 2019
Source: Family Health Development Division
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Figure 7 Worload of Primary Care Laboratories by Clinic Type in each State for 2019
WP LABUAN SABAH SARAWAK KLTN TRGN PAHANG JOHOR MELAKA N.SEMBILAN WPKL&P SELANGOR PERAK P.PINANG KEDAH PERLIS
0 2,000,000 4,000,000 6,000,000 8,000,000 10,000,000 12,000,000 14,000,000 16,000,000 KK1 KK2 KK3 KK4 KK5 KK6 KK7
Source: Family Health Development Division
Figure 18 Comparison between workload and clinic types in 2019
Source: Family Health Development Division The quality improvement initiative in primary care laboratories is timeliness of laboratory results. Since 2002, timeliness of Full Blood Count (LTAT FBC) test results have been evaluated and the necessary rectification actions were taken. Although all laboratories with a hematology analyzer were required to participate in this programme, some facilities did not participate due 37
to various reasons. However, the percentage of participating laboratories had steadily increased from 92.7 per cent in 2017 to 95.5 per cent in 2019 as shown in Table 20. This increase was partly due to the supply of new hematology analyzers under the Medical Equipment Enhancement Tenure (MEET) project thus enabling more clinics to participate with newer analyzers. The LTAT performance for the year 2017 to 2019 is shown in Figure 19. Overall, all the states achieved the set target of 95 per cent except for Sabah and Kedah. Sabah and Kedah achieved 84.2 per cent and 93.2 per cent respectively. Among the key problems identified were frequent breakdown of analyzers, insufficient staff and frequent power trip. Most of the primary care laboratories had also participated in External Quality Assurance (EQA) Programme for hematology, clinical biochemistry and HbA1c. However, participation in these programmes was voluntary and subject to availability of fund. The number of participating laboratories in EQA Programme for clinical biochemistry had increased from 175 in 2017 to 189 in 2018. This number further increased to 263 in 2019. Additionally, the participation in hematology and HbA1c EQA programme in 2019 was 452 and 237, respectively. Currently, the Public Health Laboratories assist the Division in monitoring the performance of the participating laboratories in EQA Programme for Clinical Chemistry and also for Hematology since 2019. Some laboratories also participated in EQA programmes for HIV and RPR Syphilis in compliance with Elimination of Maternal to Child Transmission (EMTCT) of HIV and Syphilis certification by WHO. Since 2017, a total of 20 laboratories have participated in an EQA programme for HIV rapid test conducted by The Institute of Medical Research (IMR) . However, due to the large number of laboratories and capacity limitations within IMR, there was no increase in the number of participating laboratories. The National Public Health Laboratory has already started an EQA programme for RPR Syphilis test for 31 laboratories since 2018. This programme was further expanded to include 56 laboratories in 2019. In addition the National Public Health Laboratory also conducted an Interlaboratory Comparison (ILC) programme for syphilis beginning 2019. Currently there are 94 laboratories participating in this ILC programme. In addition to the quality improvement activities that are currently being carried out, some states have identified selected clinics to prepare for MS ISO 15189 certification. However, the majority of the primary care laboratories are not equipped for ISO accreditation. Therefore, the Division has worked together with Department of Standard Malaysia (DSM) to establish a minimum Standard Quality for primary care laboratories. In the next few years, the Division will work closely with the DSM to ensure all primary care laboratories could complies with this minimum standard requirement before moving towards ISO accreditation. In 2019, the Division carried out an evaluation on 9 primary care laboratories using a checklist based on this minimum standard. Findings from this exercise has showed that many laboratories did not have standard operating procedures (SOPs) in place. Thus, it was decided that each state coordinator would work towards establishing the commonly used SOPs which can be used for training purposes and be included in a quality system in future.
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Table 20 Number of Laboratories Participating in LTAT FBC (2017-2019) Item Performance
2017 2018 2019
Number of labs with Haematology Analyser 690 673 715
Number of labs participating in QAP 640 671 683 (92.7%) (92.2%) (95.5%)
Source: Family Health Development Division
Figure 19 Performance of Laboratories in LTAT for FBC by State (2017-2019)
Source: Family Health Development Division
4.4 Medical Equipment Enhancement Tenure (MEET) MEET consists of a comprehensive maintenance and procurement of biomedical equipment for primary care facilities under the contract agreement between the Ministry of Health and Quantum Medical Solutions Sdn Bhd (QMS). The MEET contract includes all the states except Perlis, Kedah, Kelantan, Terengganu and Pahang. The contract agreement was signed on 17 April 2014 which included a total of 52,211 existing biomedical equipment in 1,807 health facilities. Under the contract, 33,710 new biomedical equipment shall be procured by the 39
company and supplied to the facilities. The length of the contract is 13 years for maintenance services while the procurement exercise should be completed by 2019. Under the 7th Supplementary Agreement (SA7), the scope of MEET project was expanded to include new facilities , maintenance and procurement of additional equipment for the facilities. Under the SA7, an additional 235 clinics were included in 2018 bringing the total number of facilities under MEET to 2,055. In 2019, this number was further increased to 2068 as shown in Figure 20. Currently, 46,207 biomedical equipment including the procured equipment are maintained under MEET. However, the total number of equipment under maintenance has decreased from the original number in the contract due to removal of equipment beyond economic repair (BER) and outdated equipment no longer in use. So far, 29,069 new biomedical equipment comprising of 65 categories have been supplied to the states in 12 batches as shown in Figure 21. Under the 7th supplementary agreement, an additional 2,225 equipment were procured and supplied. However, there was delay in supply of certain categories of equipment mainly due to late completion of construction work involved. This includes x-ray machine, processor and biosafety cabinets. Thus, the supply of these equipment was extended till the first half of 2020.
Figure 20 Number of Facilities under MEET by State (2017-2019)
Source: Family Health Development Division
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Figure 21 Number of Equipment Supplied under MEET in each Batch (Batch 1 to 12)
Source: Family Health Development Division
4.5 Enhanced Primary Health Care Initiative (EnPHC) Enhanced Primary Healthcare (EnPHC) was initiated as a demonstration project following MHSR recommendation for MOH to strengthen PHC in Malaysia. The main objective is to enhance the health of Malaysian through a systematic approach to manage Non-Communicable Diseases (NCD) at primary care level. The major components of the initiative were 1) prevention, early detection and treatment of NCD screening program at community level, 2) integrated and person centred care concept at the health clinic and 3) seamless care between primary and secondary level. The project, which was launched for one-year period from July 2017 to July 2018, involved 20 intervention health clinics comprised of 11 health clinics in Johor and nine (9) health clinics in Selangor. In 2019, the project was scaled up to 20 more new sites, six (6) health clinics in Selangor , 11 health clinics in Johor and three (3) health clinics in Negeri Sembilan. Under EnPHC project , eight main indicators were monitored monthly i.e the percentage of population enrolled and screened; number of newly diagnosed Diabetes, Hypertension and Hyperlipidemia, percentage of medication adherence refills appointment and percentage of compliance to clinic and hospital appointment. Findings from 1st year implementation period showed that there were still many undiagnosed NCD in the community even though only less than a quarter of the enrolled population were screened. The improvement in the NCD case management in the clinic setting and enhancement of referral network showed to be effective in ensuring patient compliance, hence 41
contribute to better outcome and control of NCD cases. However, there were many challenges faced by the clinics that need to be addressed especially on the shortage of manpower, insufficient budget, old infrastructures, unavailability of ICT system and lack of support at the local level. All these issues must be seriously looked into for any future scale-up plan to ensure optimum benefit to the community and sustainability of such initiative.
Table 21 List of health clinics involved in EnPHC 2017-2019 States Year
2017-2018 2019
Johor KK Pontian, Pontian KK Benut, Pontian KK Pekan Nenas, Pontian KK Kayu Ara Pasang, Pontian KK Ayer Baloi, Pontian KK Parit Ismail, Pontian KK Parit Jawa, Muar KK Serkat, Pontian KK Bukit Pasir, Muar KK Penerok, Pontian KK Rengit, Batu Pahat KK Ayer Hitam, Kota Tinggi KK Parit Sulong, Batu Pahat KK Waha, Kota Tinggi KK Sri Gading, Batu Pahat KK Air Tawar 5, Kota Tinggi KK Batu Anam, Segamat KK Parit Bakar, Muar KK Buloh Kasap, Segamat KK Bekok, Segamat KK Air Tawar 2, Kota Tinggi KK Sagil, Segamat
Selangor KK Telok Panglima Garang, KK Sg Lui, Hulu Langat Kuala Langat KK Bestari Jaya, Kuala Selangor KK Telok Datuk, Kuala Langat KK Kuala Selangor, Kuala Selangor KK Bukit Changgang, Kuala KK Kapar, Klang Langat KK Kalumpang, Hulu Selangor KK Ulu Yam Bharu, Hulu Selangor KK Salak, Sepang KK Tg. Karang, Kuala Selangor KK Beranang, Hulu Langat KK Balakong, Hulu Langat KK Sg. Besar, Sabak Bernam
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KK Batu Arang, Gombak
Negeri Sembilan KK Seremban 2, Seremban KK Sikamat, Seremban KK Mantin, Seremban
Source: Family Health Development Division, MOH
Picture 9 Eight key indicators of EnPHC and achievement (2017-2019)
Source: Family Health Development Division,
4.6 Dietetic Services Primary Health Care Dietetic services have been introduced in health clinics since 2010. The total number of post was 67 and 64 positions have been filled up (95.5 per cent). In 2019, the main focus was on preparation for the implementation of Allied Health Profession (AHP) Act 774 and developing strategies to increase access to primary dietetic services. The coverage of dietetic services at health clinic increased from 32.8 percent (2018) to 43.1 percent (2019).
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Table 22 Dietitian Post, Vacant Post And Dietetic Coverage In Health Care Clinic 2019. Health Clinic
No States Total Health Health Clinic with Health Clinic with Clinic Resident Dietitian Dietetic Services
n % n % 1 Perlis 9 1 11.1 9 100 2 Kedah 61 4 6.6 35 57.4 3 P. Pinang 30 2 6.7 22 73.3 4 Perak 87 3 3.4 30 34.5 5 Selangor 80 8 10.0 63 78.8 6 WPKL & Putrajaya 19 9 47.4 19 100 7 Negeri Sembilan 50 5 10.0 24 48.0 8 Melaka 32 4 12.5 24 75.0 9 Johor 96 5 5.2 59 61.5 10 Pahang 86 5 5.8 19 22.1 11 Terengganu 50 7 14.0 45 90.0 12 Kelantan 89 4 2.0 45 50.6 13 Sarawak 205 4 2.0 17 8.3 14 Sabah 120 3 2.5 26 21.7 15 WP Labuan 2 0 0.0 1 50.0 1016 64 6.3 438 43.1 Source: Family Health Development Division, MOH With increasing non-communicable disease (NCD) burden, the number of cases handled by dietitians were also increased in 2019 (Table 23). The Medical Nutrition Therapy for NCD patient such as Gestational Diabetes, Diabetes Mellitus and Kidney Disease had significantly increased. The quality indicator used to monitor diabetes cases for dietetic service was the percentage of HbA1c reduction among patients who have received dietetic consultation within six (6) months. A total of 1219 (61.91 per cent) patients who met the criteria were managed to reduce at least one (1) per cent of HbA1c within six (6) months as shown in Table 24.
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Table 23 Workload of Primary Health Care Dietetic Services States Number Total Total Case Total Total Total All of Clinic Workloa Seen By Health Health Workload With d of Visiting Clinic Cases Clinic Visiting Primer Hospital Referred To Case Dietitian Dietitian Dietitian Hospital Seen By From To Health Outpatient Hospital Hospital Clinic Dietitian Perlis 4 1,568 478 0 478 2,046
Kedah 7 9,477 3,714 3,004 6,718 16,195
Pulau 9 4,857 869 1,471 2,340 7,197 Pinang
Perak 15 5,684 3,011 3,607 6,618 12,302
Selangor 19 26,569 2,440 1,382 3,822 30,391
WP Kl & PJ 0 13,467 0 26 26 13,493
Negeri 6 7,991 669 807 1,476 9,467 Sembilan
Melaka 2 6,007 211 399 610 6,617
Johor 9 11,694 838 1,539 2,377 14,071
Pahang 0 9,181 0 584 584 9,765
Terengganu 2 14,269 378 54 432 14,701
Kelantan 7 7,448 945 302 1,247 8,695
Sarawak 15 6,507 1,977 2,629 4,606 11,113
Sabah 4 6,583 613 1,157 1,770 8,353
Labuan 1 151 623 774 774
Total 100 131,302 16,294 17,584 33,878 165,180
Source: Family Health Development Division, MOH
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Table 24 Quality indicator for Primary Health Cara Dietetic Services 2017, 2018 & 2019 No. Activities Quality Target 2017 2018 2019 indicator
Reduction of Percentage 60% 774/1219 574/891 1219/1969 1% of HbA1c of HbA1c (63.5%) (64.42%) (61.91%) within 6 month reduction post dietetic consultation
*Jun 2017 – Jun 2019
Source: Family Health Development Division. MOH
4.7 Pharmacy services Human resource is an important element of ensuring an optimal pharmaceutical care in primary care facilities. For the year 2019, the number of facilities with pharmacists was 786 (77.4 per cent) for Health Clinics, 40 (13.4 per cent) for Community Clinics and 38 (41.8 per cent) for Maternal and Child Health Clinics. Meanwhile, 775 (76.3 per cent) health clinics were placed with the Assistant Pharmacy Officer compared to only 761 health clinics in 2018 (an increase by 1.8 per cent). In term of filling up post, 660 (65.0 per cent) health clinics were filled up with Pharmacy Officer , 1.8 per cent increased as compared to 2018 (648 health clinics). This increase was mainly due to the State Health Department's efforts in relocating staff through redeployment as recommended by the Central Agency. Provisional Pharmacists (PRPs) are only allowed to undergo provisional training in the training premises either public or private that are listed in the Second Schedule, Pharmacist Registration Act 1951. Training for Trainee Pharmacy Officers in health clinics started in 2017. As of 2019, 150 health clinics were recognized as training centers including on-the-job training for Inventory Management, Methadone Treatment and Medication Therapy Adherence Clinic (MTAC) modules. The total number of new PRPs trainee was 227. Pharmaceutical services in primary care have been strengthened through the implementation of the PhIS and CPS System. The system has been developed and implemented under the Perjanjian Konsesi Makmal Ubat dan Stor ,KKM, since 2011 to assist and facilitate the delivery of pharmaceutical services in the field. A total of 999 health clinics was dentified and equipped with ICT equipment, PhIS and CPS systems. The type of implementation was determined based on several factors such as infrastructure readiness , Gov-Net 1 line availability and few other technical issues (Figure 21). For the health clinics that have implemented the Full Base and Pharmacy Base Systems, all modules are available in PhIS and CPS System whereas for the health clinics which have been installed with Inventory -D and Indent, they could only use procurement modules and sub modules involving Indent only. By using this system, all drugs, non -drug including reagent procurement could be carried out and monitored more efficiently.
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Figure 21 PhIS &CPS Implementation Type In Health Clinic
Source: Pharmacy Services Programme
Note: 1. Standard Full Base- Prescription provided by Medical Officers through PhIS & CPS 2. Standard Pharmacy Base - Prescription information is locked in by a pharmacist 3. Inventory Base - Only use the inventory module 4.Indent Base - Use only the submodule in the inventory module
In 2019, there was 1.9 per cent increase in the number of prescriptions received compared to 2018. The number of filtered prescriptions was 96.1 per cent and 0.89 per cent out of that prescriptions were intervened. The types of interventions that were identified as shown in figure 7.2. Information from the report of these interventions were presented at relevant pharmacy quality meetings for improvement.
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Figure 22 Precriptions Intervention Percentage By Intervention Type in Health Clinic
Source: Pharmacy Services Programme For incomplete prescriptions, among the components that were monitored were patient data, medication, dosage, frequency, duration as well as signatures and prescriber stamps . The inappropriate regimen involved the medication, dosage, frequency and duration of the prescribed medication while the inappropriate prescription included misdiagnosis, polypharmacy, contraindications, drug interactions and incompatibility. Medicines not listed in of facilities formulary , unclear writing and the authenticity were categorized under others. A proper supply of medicine based on 5B concepts is essential to ensure patients will have the optimum pharmacotherapy effect of the drug. The extemporaneous preparations should be prepared for drugs if the dosage form and dose are not commercially available. The 2018 data showed that only 27.5 per ce of health clinics prepared extemporaneous preparations compared to hospitals. In order to emphasize the importance of preparation at the health clinic and to increase knowledge and procedures in implementing extemporaneous preparation, a Good Preparation Practice workshop was held on July 24-25, 2019 involving Pharmacy Officers and Assistant Pharmacy Officers from the health clinic.
The Stop Smoking Services are one of the strategies in health clinics to eradicate smoking habit among patients and the general public. Stop Smoking Clinic Services at health clinics are managed by trained personnel including Pharmacy Officers if patients require drugs treatment . In 2019 , there were 16,169 patients who registered with the Stop Smoking Clinic Among them, 8367 (51 per cent) patients had received medication and were referred for pharmacotherapy counseling.
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The delivery process of Pharmacy Services in health clinic has also been strengthened with the revised and updated Pharmacy Services Supervisory Checklist 2019 to replace the checklist that was released in 2017. The briefing sessions on the implementation of the supervisory checklist were organized through 4 series of workshop at district and state level. • Feb 26-27, 2019 (Selangor, KL&P, Melaka, N9, Johor) • March 7-8, 2019 (Sabah, Sarawak, Labuan) • March 11-12, 2019 (Perlis, Kedah, Penang, Perak) • March 18-19, 2019 (Pahang, Terengganu, Kelantan) The use of standard checklists in the implementation of the supervisory activities has helped to ensure consistency in pharmaceutical services delivery in health clinics including units that utilize and store medicines, non-medicines and reagents. This updated checklist was also used in 72 (31 per cent) health clinics without pharmacists. Under the MEET (Medical Equipment Enhancement Tenure) project, there are five (5) medical assets listed for pharmacy units i.e Scales Clinical Pharmacy, Refrigerator Pharmacy (1400L), Refrigerator Pharmacy (700L), Refrigerator Pharmacy (400L) and Pump Pharmacy. All of them (Table 23) have been supplied except for the Pump Pharmacy which will be fully delivered in 2020.
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Table 23 Pharmacy Asset Supply Status Under the MEET Project
Items Number (UNIT) Delivery Status
Refrigerator Pharmacy (1400l) 48 Fully supplied
Refrigerator Pharmacy (700l) 75 Fully supplied
Refrigerator Pharmacy (400l) 468 Fully supplied
Clinical Scale Pharmacy 648 Fully supplied 209- Supplied Pump Pharmacy 582 373- Delayed
Source: Family Health Development Division, MOH
5 QUALITY AND INNOVATION SECTOR
5.1 Antimicrobial Stewardship Program (AMS) In 2019, the Antimicrobial Stewardship (AMS) program in primary health care continued all its activities in all health clinics with Family Medicine Specialist. The AMS monitoring and reporting activities include AMS clinical audit, AMS structure audit and Point Prevalence Survey (PPS). The percentages of health clinics performed in these three audits were 95.6 percent, 94.9 per cent and 98.4 per cent respectively. An appropriate antibiotic prescribing should be assessed through the implementation of AMS clinical audit. Percentages of the performance of appropriate antibiotic prescriptions should be calculated based on clinical audit score of 80 to 100. In 2019, appropriate antibiotic prescriptions was 53.3 percent. The analysis of AMS Clinical Audit showed that elements of statement with regards to drug allergy, correct duration of prescribed antibiotic and health education on compliance and side effects were the lowest audit score of all elements. The organization's AMS program performance is evaluated based on AMS Structure Audit score in which the target is 80 percent. A total of 97.7 percent of the health clinics performing the structure audit exceed 80 percent. All participating health clinics have full scores for elements of the PPS survey. Analysis of AMS Structure Audit revealed that elements of communicates with patient about antibiotic indication, assess and share performance on AMS surveillance and as well as availability of public awareness-raising tools scored the lowest for most of the states. The percentage of antibiotic prescriptions for cases with the diagnosis of Upper Respiratory Tract Infection (URTI) at the health clinic was 48 percent, decreased by 0.7 percent compared
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to the pilot study of the Antibiotic Point Prevalence Survey in Primary Care conducted in 2015 (48.7 percent). All of 2019’s AMS audits and survey findings will be used as the baseline achievements for the following years.
Figure 23 Percentage of Health Clinics Performed AMS Clinical Audit by States in 2019
Source : Family Health Development Division
Figure 24 Percentage of Appropriate Antibiotic Prescription by States in 2019
Source : Family Health Development Division
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Figure 25 Percentage of Health Clinics performed AMS Structure Audit by States in 2019
Source : Family Health Development Division
Figure 26 AMS Structure Audit Performance Exceeding 80 Percents by States in 2019
Source : Family Health Development Division
Table 24 AMS Structure Audit Performance by Elements in 2019
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PERFORMANCE NO DOMAIN/ELEMENT (PERCENTAGE)
1. COMMITMENT
1(a) Has dedicated AMS team 96.7
1(b) Incorporates AMS agenda in management meeting 81.2
1(c) Communicates with patient about antibiotic indication 71.9
2. ACTION
2(a) Availability of treatment guidelines and clinical pathways 98.0
2(b) Formulary restriction based on prescriber category and local setting 96.0
2(c) Implementation of AMS clinical audit 99.7
3. TRACKING AND REPORTING
3(a) Track and report antibiotic utilization using Dailt Defined Dose (DDD) 91.1
3(b) Implementation of antibiotic Point Prevalence Survey (PPS) 100
3(c) Assess and share performance on AMS surveillance and audit 68.6
4. EDUCATION
4(a) Continous Medical Education (CME) 90.8
4(b) Prescribing aids for prescribers 92.7
4(c) Public awareness-raising tools 87.5
Source : Family Health Development Division
5.2 Malaysian Patient Safety Goals Patient Safety Goals reporting in primary health care has been implemented since 2013. All health clinics including stand-alone maternal and child health clinics are required to implement, monitor and report on their annual performance through e-goals patient safety. The four goals related to primary healthcare facilities are; clinical governance, medication safety, reducing falls and incident reporting. In 2019, only 85.3 percent of health clinics reported their performance, decreased by 8.2 percent compared to 2018 (93.5 percent), which was the lowest performance within five (5) years. A total of 230 incidents were reported in 2019, an increase of 60.8 percent compared to those of 2018 (143 incidents). Investigation error was the most frequent incident reported (59 incidents), followed by patient fall (52 incidents) and decision making error (41 incidents).
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Figure 27 National MPSG Performance from 2015 to 2019
Source : Family Health Development Division
Figure 28 Numbers of reported incidents in 2019
Source : Family Health Development Division
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Figure 29 Number of reported incidents from 2015 to 2019
Source : Family Health Development Division
5.3 Infection Prevention and Control in Primary Health Care Infection Prevention and Control activities in Primary Health Care were continued in 2019 with the implementation of the Standard Precautions Compliance Audit and Hand Hygiene Compliance Survey. 780 facilities consisting of health clinics, maternal and child health clinics, community clinics, Klinik Komuniti (KKOM) and mobile clinics were audited in 2019 as compared to 210 that had been set as the denominator. The national percentage of standard precautions compliance was 95.1 per cent, increased 0.9 per cent from 2018. The percentage of compliance in all domains of standard precautions increased from 2018 in the range of 92.8 percent to 96.6 percent with the exception of cough etiquette which decreased 0.2 percent. The highest compliance rate was achieved in the PPE domain while the lowest compliance rate was achieved in the disinfection and sterilization domain. A total of 258 health clinics had participated in Hand Hygiene Compliance Survey in 2019, 83 percent more than the targeted set (141 health clinics). 12 states had some degrees of increases in Hand Hygiene Compliance rate compared to eight (8) states in 2018. However, the national Hand Hygiene Compliance percentage decreased by five (5) percent, from 94 percent to 89 percent in 2019. This is because 4 states that representing a large number of denominators (41.9 percent) of the total national denominators achieved relatively low performance of 82.1 to 85 percent.
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Figure 30 Percentage of Infection Prevention and Control Compliance Audit by State, 2015 to 2019
Source: Bahagian Pembangunan Kesihatan Keluarga Figure 31 Compliance in Domains of Standard Precautions , 2015 to 2019
Source: Bahagian Pembangunan Kesihatan Keluarga
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Figure 32 Hand Hygiene Compliance Survey by State ,2015 to 2019
Source: Bahagian Pembangunan Kesihatan Keluarga
5.4 QAP Friendly Clinic and QAP Appropriate Management of Asthma Of the year of 2019, we can see a significant progress in the number of participating clinics implementing QAP Friendly Clinic and QAP Asthma. After 3 years of the discontinuation of the former web-based QAP Survey Recording System whereby all the survey records were documented and analysed manually this sector had aggressively put efforts in making the use of a newly designed Web Based QAP Recording System into a reality since 2016 by conducting several series of trainings at national level and state levels.
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Figure 33: QAP Friendly Clinic’s medians of Figure 34:QAP Friendly Clinic’s percentages of percentages of respondents with 80% marks nation-wide participating clinics from 2013 to from 2013 to 2019. 2019.
Source : Family Health Development Division Figure 33 above shows that no progress in the median of the percentages of respondents with 80 per cent marks at national level in QAP Friendly Clinic (QAP Klinik Kawanku), indicating that the performance is now at its plateau at the median of 98 per cent. However, and Chart 12 shows a significant increase in the number and percentage of nation-wide participating clinics from 91.1 per cent to 96.0 per cent. Figure 35 and Figure 36 below on the other hand, show a significant increase in the median of the percentages of respondents with 6/6 marks from 73.3 per cent to 80 per cent and a slight increase in the percentage of nation-wide participating clinics from 87.0 per cent to 89.1 per cent. Figure 35: QAP Asthma’s median of the Figure 36: QAP Asthma’s median of the percentages of respondents with 6/6 marks percentages of respondents with 6/6 marks
Source : Family Health Development Division
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Two obvious reasons may have contributed to the increases in the National performance and percentages of participating clinics of both QA programs. First, we have received information that several State Health Departments had conducted training sessions at their levels in 2019, which had facilitated the users to make full use of the system and therefore reduce data entry errors and increase the ease of administering the surveys. Second, continuous efforts in all levels in complying with the methodologies of both QAP studies, especially in QAP Asthma with regards to inhaler and medications.
5.5 Waiting Time Monitoring at Health Clinics The waiting time at the Health Clinic is maintained as one of the indicators in the Ministry of Health's Client Charter 2019. A total of 89 health clinics equipped with Tele Primary Care (TPC) facilities from seven states are involved in this monitoring. The target percentage of customers waiting less than 90 minutes to see a Medical Officer is 86 percent. Sabah, Sarawak and Perlis are the three states that continue to achieve less than the targets set by MOH in 2019.
Figure 37 Waiting Time Performance less than 90 minutes by states
Source : Family Health Development Division
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6 PRIMARY POLICY DEVELOPMENT SECTOR
6.1 Health Services In Immigration Depot Illegal immigrants (PATI) are immigrants who live in a country without complying with the immigration laws. The presence of PATI threatens the social aspects of the country, especially the health aspects of infectious diseases such as HIV, TB, hepatitis and others. The main laws relating to detention and prison facilities are Prisons Act 1995 (Act 537), Prisons Regulations 2000 and Immigration Depot Management (2003) Regulations 2003. Malaysia Ministry of Health (MOH) provides the mobile medical team from the nearest health clinic as an in-charge health clinic to provide treatment and refer needed cases at immigration depot every two (2) weeks as per Circular Malaysia Commission Bill. 8/2008 dated August 4, 2008. MOH has placed fourteen (14) assistant medical officer (AMO) as cadre posts at 14 immigration depots nationwide since 2015 and has added a new PPP post approved in 2019 with eleven (11) posts to fill as shown in Table 25.
Table 25 Location of Immigration Depot with the Assignment of Assistant Medical Officer In-charge Health New Post No. State Institution Current Post Clinic 2019
1 Kedah Belantik KK Sik 1 +1
2 Pulau Pinang Juru KK Bukit Minyak 1
3 Perak Langkap KK Langkap 1 +1
4 Selangor Semenyih KK Semenyih 1 +1
5 Sepang KK Dengkil 1 +1
6 WP Kuala Lumpur Bukit Jalil KK Sg Besi 1 +1
7 WP Putrajaya Presint 2 KK Presint 18 No Post
8 N. Sembilan Lenggeng KK Lenggeng 1 +1
9 Melaka Machap Umbo KK Machap Baru 1 +1
10 Johor Pekan Nenas KK Pekan Nenas 1 +1
11 Pahang Kemayan KK Kemayan 1 +1
12 Terengganu Ajil KK Ajil 1 +1
13 Kelantan Tanah Merah KK Tanah Merah 1
14 Sabah Tawau KK Tawau No Post
15 Sandakan KK Sandakan No Post
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In-charge Health New Post No. State Institution Current Post Clinic 2019
16 Papar KK Papar No Post
17 Kota Kinabalu KK Menggatal No Post
18 Sarawak Semuja KK Triboh 1 +1
19 Bekenu KK Bekenu 1
Total Posts 14 + 11
Source : Family Health Development Division
Figure 38 Patient Visits to Immigration Depot Clinic for January Until December 2019
Source : Family Health Development Division The top five (5) depots with highest patient arrivals are Semenyih Immigration Depot, Selangor, KLIA Immigration Depot, Precinct 2 Immigration Depot, Putrajaya, Pekan Nenas Immigration Depot, Johor and Immigration Depot Semuja, Sarawak. This trend is closely related to the location of the depot in the densely populated area of industrial development and the number of migrants temporarily stationed at the depot. These depots are also located near the country entrance.
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Figure 39 Patient Visits from 2014 to 2019
Source: Department of Immigration
The graph above shows the trend of the number of migrants receiving treatment at the depot clinic for 2014 to 2019. There was an increase in 2015 following the influx of Rohingya immigrants to Belantik Immigration Depot. This trend expected to increase in 2019 in tandem with the increasing number of new arrivals to the depots before the deportation. Figure 40 Number of Patients Visits by Citizenship for the Year 2019
Source: Department of Immigration Indonesian immigrants are the most populous, followed by the Philippines, Bangladesh, Myanmar and other countries (Cambodia, Laos, Nigeria, Sudan, Yemen, Iran, Serbia, Bosnia and other African, Arab and European countries).
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Figure 41 Number of Attendees by Age for 2019
Source: Department of Immigration Prisoners between the ages of 20-59 are the highest in getting treatment, indicating the age group of immigrants staying in the depot. There are also senior citizens aged 60 and above and children aged 19 and below indicate there are at risk group being placed here. Figure 42 Ten (10) Causes of Major Illness at Immigration Depot for 2019
Source: Department of Immigration
Diseases of the respiratory system are the major diseases with the highest incidence, followed by certain infectious and parasitic diseases and other diseases as shown in the diagram above.
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6.2 Clinical Service After The Office Time (Extended Hour) The service provided to increase community access to after-hours services as well as to help reduce congestion in the Emergency Zone, Emergency & Trauma Department of nearby hospitals. 74 health clinics have implemented this service in 2019. Selangor still has the highest number of clinics and the highest number of attendance using this service. Table 26 List of Health Clinics Executing Extended Hour Services (1) Klinik Kesihatan Klinik Kesihatan Bil. Negeri Bil. Negeri (KK) (KK)
1. Perlis KK Kangar 20. WP KL & KK Presint 9 Putrajaya 2. KK Kuala Perlis 21. KK Jinjang
3. Kedah KK Alor Setar 22. KK Kg Pandan
4. KK Kulim 23. KK Kuala Lumpur
5. KK Sg. Petani 24. Melaka KK Peringgit
6. KK Kuah 25. KK Ayer Keroh
7. KK Padang Matsirat 26. KK Jasin
8. Perak KK Greentown 27. KK Merlimau
9. KK Sitiawan 28. KK Masjid Tanah
10. KK Kamunting 29. KK Alor Gajah
11. KK Taiping 30. Johor KK Mahmoodiah
12. KK Jalan Damai 31. KK Sultan Ismail
13. KK Teluk Intan 32. KK Maharani
14. KK Tanjung Malim 33. KK Payamas
15. Sarawak KK Jalan Masjid 34. KK Mengkibol
16. KK Miri 35. KK Batu Pahat
17. KK Lanang 36. KK Pontian
18. KK Sarikei 37. KK Kulai Besar
19. KK Bintulu
Source : Family Health Development Division
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Table 27 List of Health Clinics Executing Extended Hour Services (2) Bil. Negeri Klinik Kesihatan (KK) Bil. Negeri Klinik Kesihatan (KK)
38. Pahang KK Kuantan 58. Selangor KK Anika
39. KK Mentakab 59. KK Pandamaran
40. KK Maran 60. KK Selayang Baru
41. KK Jaya Gading 61. KK Sg. Buloh
42. Terengganu KK Batu Rakit 62. KK Puchong
43. KK Kuala Berang 63. KK Seksyen 7, Shah Alam
44. KK Kuala Dungun 64. KK Seksyen 19, Shah Alam
45. KK Batu 2 1/2 65. KK Kajang
46. Kelantan KKB Kota Bharu 66. KK Bandar Baru Bangi
47. KKB Bachok 67. KK Taman Medan
48. KK Wakaf Baru 68. KK Ampang
49. KK Pasir Mas 69. KK Bandar Botanik
50. Sabah KK Sandakan 70. Pulau Pinang KK Seberang Jaya
51. KK Luyang 71. KK Bayan Baru
52. KK Putatan 72. Negeri KK Seremban Sembilan 53. KK Inanam 73. KK Port Dickson
54. KK Lahad Datu 74. KK Bahau
55. KK Penampang
56. KK Menggatal
57. KK Tawau
Source : Family Health Development Division
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Figure 43 Comparison of Extended Hours Patient Services Visits from 2011 to 2019
73 KK
Source : Family Health Development Division Figure 44 Comparison of Number of Emergency Case Attributes versus Non-Emergency Cases in Extended Hours Health Clinics January-December 2019
Source : Family Health Development Division Non-emergency cases dominate the attendance at extended hour health clinics. This is in line with the objective of this service aimed at reducing the concentration of non-emergency cases at the nearby Emergency & Trauma Department. Selangor has the highest number of cases compared to other states and has the largest number of extended-hour health clinics at 12.
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6.3 Health Clinic Advisory Panel (PPKK) 12,828 members of the Health Clinic Advisory Panel have been appointed for January 2019 to December 2020 session. The number of new PPKK increased from 866 (81 per cent) to 937 (94 per cent) with 893 health clinics, 35 maternal & child health clinics as well as 9 rural clinics. Table 28 Distribution of Members of the 2019 Health Clinic Advisory Panel Numbers of Numbers of Health Numbers of Health No. State PPKK Clinics Clinics with PPKK members
1 Perlis 9 9 119
2 Kedah 59 55+6 (KKIA) 865
3 Pulau Pinang 30 28+3 (KKIA) 422
4 Perak 86 79+4 (KKIA) 1109
5 Selangor 79 70 1171
6 WP KL & Putrajaya 17 17 232
7 N. Sembilan 49 42 585
8 Melaka 31 27 376
9 Johor 95 95+3 (KKIA) 1047
10 Pahang 85 78+4 (KKIA) 1125
11 Terengganu 49 42 768
12 Kelantan 88 83 1214
13 Sarawak 212 161+2 (KKIA) 2374
14 Sabah 106 106+13(KKIA)+9(KD) 1405
15 WP Labuan 1 1 16
TOTAL 996 937 12,828
Source : Family Health Development Division A total of RM4.4 million has been allocated in 2019 to the Health Clinic Advisory Panel throughout Malaysia. Of which RM5,000 is allocated to each PPKK to carry out health activities either through direct or warrant accounts.
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Figure 45 Total PPKK Financial Allocation for 2012-2019
5,000,000 4,410,000 4,275,000 4,320,000 4,500,000 4,110,000 4,125,000 4,135,000 3,835,000 4,000,000 3,615,000 3,500,000 3,000,000 2,500,000 PPKK FINANCIAL ALLOCATION FOR 2,000,000 2012-2019 1,500,000 1,000,000 500,000 0 2012 2013 2014 2015 2016 2017 2018 2019
Source : Family Health Development Division
Figure 46 Total PPKK Financial Allocation for 2019 by State
800,000 750,000
700,000 630,000 600,000 490,000 500,000 410,000 415,000 385,000 400,000 345,000 FINANCIAL 295,000 ALLOCATION 300,000 210,000 200,000 145,000 135,000 85,000 65,000 100,000 45,000 5,000 0
Source : Family Health Development Division
The implementation of the indicators for the Health Clinic Advisory Panel commenced in 2015: a) Percentage of students who succeed in losing 5 per cent in six (6) months.
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b) Percentage of TB health promotion activities and sputum sampling conducted by the PPKK in the community. c) Percentage of senior citizens who register with health clinics and receive senior health services. d) Percentage of reproductive health promotion activities by the PPKK conducted on adolescents in the community. The preferred indicators were senior citizens health services of 140 health clinics and TB health screening promotion community in the community of 93 clinics.
Table 29 Number of Activities (Indicators) of the PPKK for 2019 Obese TB Promotion Senior Citizen Adolescent No. State Student Indicator Indicator Indicator Indicator
1 Perlis - 4 4 1
2 Kedah - - 2 -
3 Pulau Pinang - - 3 1
4 Perak 12 17 27 15
5 Selangor 5 2 23 6
6 WP KL & Putrajaya 1 3 7 5
7 N. Sembilan - 4 4 -
8 Melaka - 5 10 4
9 Johor 2 4 4 4
10 Pahang 12 17 18 6
11 Terengganu 2 6 6 4
12 Kelantan 9 4 9 6
13 Sarawak 5 21 23 6
14 Sabah 3 6 5 4
15 WP Labuan - - 5 5
TOTAL 51 93 150 67
Source : Family Health Development Division
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In addition to the above activities, the PPKK also conducts health activities with local communities such as health camps, healthy living campaigns, Health Day Celebration programs and cooperation with Team NCD and COMBI in their respective districts. The excellent community response and the presence of many nearby counties also have a profound impact on the field community. Table 30 Number of Activities (Other) PPKK Year 2019 Health Health Day Smoking Screening/ Celebration/ Dengue NCD/ No. State Cessation Physical Cancer Campaign Methadone Campaign Activity Awareness 1 Perlis - - - - - 2 Kedah 4 - - - 1 3 Pulau Pinang 4 1 - - - 4 Perak 10 1 1 1 1 5 Selangor 7 1 - 3 3 6 WP KL & Putrajaya 9 2 - - 6 7 N.Sembilan - - - - - 8 Melaka 9 2 1 1 2 9 Johor - - - - - 10 Pahang 6 1 - - 4 11 Terengganu 7 6 - - 5 12 Kelantan 4 1 - 1 - 13 Sarawak 2 1 - - 1 14 Sabah 9 1 - 1 - 15 WP Labuan 3 1 - - 1 TOTAL 74 18 2 7 24
Source : Family Health Development Division
The Health Clinic Advisory Panel also visits the PPKK in other states to see and discuss together how to enhance the PPKK's creativity in conducting health activities with the local community. In June 2019, a visit made to the PPKK Kuala Berang, Hulu Terengganu, Terengganu and in October 2019 a visit to the PPKK Tendong & PPKK Teluk Renjuna, Pasir Mas, Kelantan where all the representatives of the state PPKK participated. Representatives of the PPKK itself carried out presentation of health related activities in their community.
6.4 Family Doctor Concept (FDC) The Family Doctor Concept (FDC) is one of the initiatives under the Ministry of Health's Transformation Program, with the aim of strengthening primary health care services in Malaysia. Starting with 14 health clinics in 2014-2015, the target is 48 health clinics each year. 70
To date, 322 health clinics have established a Primary Health Care (PHC) team out of 981 health clinics in Malaysia. Figure 47 Number of Health Clinics Implementing FDC for 2019
Source : Family Health Development Division Currently, several variations of FDC implementation models in the field remain a challenge in FDC implementation. The decision to change the tagline made during the FDC review meeting where the tagline of One PHC team, One Family adopted as the One Doctor, One Family tagline dropped. A workshop on FDC guidelines review as well as related items (audit checklists, FDC models, indicators, etc.) will undertake to make the implementation of the FDC uniform. For patients from outside of operational area (LKO) issues, there will be no typical zone for LKO. LKO can be included in the existing zone but there needs to be a mechanism for identifying LKO patients for obtaining area denominators. LKO patients identified by placing the LKO mark on the patient's record without having to know it.
6.5 Mobile Health Services Mobile Clinic Services are provided to improve access to health for rural and remote areas particularly to the population who are residing in estate, villages, Orang Asli Settlement and islands. These services provided as an outreach programme from static facilities of Ministry of Malaysia. In 2019, 246 mobile health clinic teams delivered services by land (4WD & bus), water (boat) and air (helicopter) as shown in Table 31. Availability of Mobile health services to 71
the rural population is in line with Sustainable Development Goals and Universal Health Coverage, leave no one behind. The basic services provided are maternal and child health including immunization, treatment of minor illnesses, control of communicable diseases, school health services, environmental health and sanitation and emergency care. Table 31 Total Mobile Health Team For 2019 Land Water Air KB Bus/Boat
NO States Small Total 4WD/Van Helicopter Bus Boat Boat
1. Kedah 3 1 - - - 4 2. Perak 16 1 1 1 - 19 3. Selangor 10 1 - 2 - 13 4. N.Sembilan 8 - - - - 8 5. Johor 17 - - 2 - 19 6. Pahang 19 1 - 4 - 24 7. Terengganu 1 - - - - 1 8. Kelantan 14 - - - - 14 9. Sabah 35 1 1 1 2 40 10. Sarawak 65 29 9 1 - 104 Total 188 34 11 11 2 246 Source : Family Health Development Division
This service has been improved with 4WD acquisitions under RP4 allocation with sum of RM1, 6 million to the states as shown in table 32. For 2019, 485,183 population have benefited from this service (figure 48). The newly diagnosed cases of Diabetes (461) and Hypertension (1038) were recorded respectively. The Upper respiratory Tract Infection is the commonest diseases that seen in ICD Classification as shown in Figure 50.
Table 32 Summary of Budget and Procurement According to the States No States Districts Placement No of Total Vehicles 1. Pahang Pekan KK Bandar Pekan 2 310,000 2. Raub KK Cheroh 3. Selangor Hulu Selangor PKD Hulu Selangor 2 310,000 4. Sepang KK Dengkil 5. Hulu Perak PKD Hulu Perak 2 310,000 6. Perak Batang Padang KK Tapah Road
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No States Districts Placement No of Total Vehicles 7. N.Sembilan Jempol KK Bandar Sri Jempol 2 310,000 8. Kuala Pilah KK Pilah JUMLAH 1,550,000 *Johor tidak dapat dibelanjakan kerana keputusan sebut harga yang tinggi.
Source : Family Health Development Division Figure 48 Total Attendances for Mobile Health Clinic from 2015-2019
550,000 500,000 450,000 400,000 350,000 300,000 250,000
Attendanves 200,000 150,000 100,000 50,000 - Negeri Kedah Perak Selangor Johor Kelantan Terengga Pahang Sabah Sarawak Malaysia Sembilan nu 2015 6,741 50,578 22,816 37,172 10,586 12,802 134 66,450 86,599 133,787 427,665 2016 5,411 108,528 18,804 42,328 30,923 13,972 190 62,229 105,590 103,803 491,778 2017 4,483 87,953 17,133 44,888 27,633 12,789 85 65,433 123,953 116,480 500,830 States 2018 4,732 90,745 16,146 43,943 27,925 13,815 132 66,213 106,985 98,175 468,811 2019 8,057 97,753 17,517 42,429 27,443 10,967 119 69,244 107,879 103,775 485,183 Source : Family Health Development Division
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Figure 49 Population Coverage Mobile Health Services For Bus and Boat 2015-2019
Source : Family Health Development Division
Figure 50 ICD 10 Classification of Top Ten Diseases
Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified 29,476 Diseases of the Musculoskeletal System and Connective Tissue 13,980
Diseases of the Skin and Subcutaneous Tissue 12,664
Disease of digestive system 18,787
Diseases of the respiratory system 107,854
Disease of the circulatory system 3,389
Diseases of the ear and mastoid process 1,845
Diseases of the eye and adnexa 2,478
Diseases of the Nervous System 2,166
Certain infectious and parasitic diseases 8,609
0 20,000 40,000 60,000 80,000 100,000 120,000
Source : Family Health Development Division
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7 PRIMARY EMERGENCY CARE SECTOR
7.1 Emergency services Health care providers at primary care are very often the first point of contact for those seeking care for injuries, infectious diseases and other emergency related illnesses. All emergency healthcare service providers should be able to evaluate and identify life-threatening signs in acutely ill patients, provide primary emergency care and refer these patients to higher-level care whenever required.
a) Response time Time is crucial when dealing with emergencies and commonly scrutinised as it can affect patient care. Response time in health clinic is the interval between the time patient comes to the clinic until he/ she is attended by the health staff.
Response time is a basic indicator of emergency medical services. The target is that 100 percent emergency cases must be attended within one minute during office hours and 95 percent of the cases seen within 15 minutes after office hours. In 2019, 99.9 percent of emergency cases received treatment during office hours within one minute while after office hours, 99.85 percent of cases received treatment within 15 minutes. Table 51 shows the achievement in response time for emergency cases in health clinics. The health care providers are more vigilant on the response time when treating patients during emergencies.
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Table 51 Percentage Of Response To Emergency Case During And After Office Hours At Health Clinics, 2015 – 2019
100.0% 100.0 99.9 99.9 99.9 99.9% 99.8% 99.8 99.8 99.7 99.7 99.7% 99.7 99.6% 99.5 99.5%
Percentage of cases 99.4% 99.3% 99.2% 2015 2016 2017 2018 2019 Year
response time in 1 minute response in time 15 minute
100.0% 100.0 99.9 99.9 99.9 99.9% 99.8% 99.8 99.8 99.7 99.7 99.7% 99.7 99.6% 99.5 99.5%
Percentage of cases 99.4% 99.3% 99.2% 2015 2016 2017 2018 2019 Year
response time in 1 minute response in time 15 minute
Source: Family Health Development Division
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b) Emergency Alert System Emergency Alert System (EAS) is installed outside the health clinic to assist patients to access emergency outpatient or maternity services after office hours by pressing the appropriate button. The health staff on duty will receive the call and attend to the case. Table 2 shows 430 health clinics and 57 rural clinics/ Maternal & Child Health Clinics were installed with EAS. Several states such as Perlis, Kedah, Penang, Selangor, Melaka and Sabah have installed EAS at rural clinics to cater for maternity cases. Perak has also installed this system in the Orang Asli Transit Centres. Overall, the response time within 15 minutes increased from 94 percent in 2015 to 98 percent in 2019 as shown in Figure 52.
There are clinics with EAS, which remain inactive because patients prefer to call the health staff directly on their mobile phones. The district health office has to re-evaluate the EAS installation in these inactive clinics.
Figure 52 Number Of Clinics With Emergency Alert System, 2019
Health Clinic Klinik Desa/KKIA Orang Asli Transit Centre 5 6
13 1 1 1 67 19 60 62 40 40 9 43 31 34 9 20
8 15 10 Numberofclinic
States
Source: Family Health Development Division
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Figure 53 Percentage Of Response Time To Cases After Office Hours At Health Clinics, 2015 – 2019
Source: Family Health Development Division
c) Medical Emergency Coordinating Centre Ambulances from health clinics assist hospitals in delivering Pre-hospital Care services. More than 400 health clinics can activated through the MECC network. The 999 emergency call received by the Medical Emergency Coordinating Centre (MECC) at the hospital will identify and channel the call to the nearest health clinic for the ambulance and health personnel to respond to the case. The health staff regularly updates MECC on the status and availability of ambulance at health clinics, which is very crucial as it can prevent delay in responding to an emergency case.
d) Training Adequate knowledge and awareness about Basic Life Support (BLS) is important to ensure that health staff are competent and confident to deliver necessary life-saving measures in case of emergencies. The percentage of assistant medical officers (AMO) trained in BLS is a Key Performance Indicator for district health officers, which is 95.0 percent. The AMO trained decreased slightly from 96.0 percent in 2018 to 91.3 percent in 2019 (Figure 54). This was mainly due to the reduction in the allocation of funds. Training of community nurses and nurses in BLS are also being closely monitored.
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Figure 54 Percentage Of Paramedics With BLS Training
Source: Family Health Development Division
7.2 Ambulance Service In 2019, all 1027 health clinics throughout Malaysia provide emergency services. 69 percent (705) of these clinics also provide ambulance service (Table 33). Those clinics without ambulance obtain service from the nearest health clinic or hospital. Ambulance service should be available in all health clinics. The number of ambulance in a clinic depends upon the workload, location of clinic or if in the MECC network.
Table 33 Availability Of Ambulance Service In Health Clinic, 2019
NUMBER OF HEALTH CLINIC HEALTH CLINIC HEALTH WITH AMBULANCE WITHOUT STATES CLINIC SERVICE AMBULANCE SERVICE NO. Percent NO. Percent Perlis 10 7 70 3 30 Kedah 61 56 92 5 8 Penang 33 19 58 14 42 Perak 88 68 77 20 23 Selangor 80 62 78 18 23 W.P.KL/ Putrajaya 19 15 79 4 21 N. Sembilan 50 39 78 11 22 Melaka 32 23 72 9 28
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NUMBER OF HEALTH CLINIC HEALTH CLINIC HEALTH WITH AMBULANCE WITHOUT STATES CLINIC SERVICE AMBULANCE SERVICE NO. Percent NO. Percent Johor 96 85 89 11 11 Pahang 86 60 70 26 30 Terengganu 51 48 94 3 6 Kelantan 94 63 67 31 33 Sabah 110 76 69 34 31 Sarawak 215 102 47 113 53 W.P.Labuan 2 1 50 1 50 Total 1027 724 70 303 30 Source: Family Health Development Division The status of ambulance as of December 2019 showed that, 67 percent (695) were in good condition, 3 percent (31) under repair, 14 percent (147) in the process of Beyond Economical repair (BER), four (4) percent (42) BER and 12 percent (126) condemned (Table 34 and Figure 55). 4WD ambulance are provided for health clinics in remote areas with difficult geographical terrain.
Table 34 Status Of Ambulance At Health Clinic 2019
PROCESS CONDEM STATES GOOD REPAIR BER TOTAL BER NED Perlis 8 0 0 6 6 20 Kedah 49 1 13 9 3 75 Penang 14 0 2 0 8 24 Perak 68 1 17 3 2 91 Selangor 67 6 14 7 14 108 W.P Kuala Lumpur/ 17 0 4 0 0 21 Putrajaya N. Sembilan 31 3 5 2 11 52 Melaka 18 0 7 0 3 28 Johor 89 3 11 1 9 113 Pahang 52 3 7 6 17 85 Terengganu 37 1 15 2 5 60 Kelantan 61 2 17 0 22 102 80
Sabah 79 3 30 3 0 115 Sarawak 104 8 4 2 26 144 W.P.Labuan 1 0 1 1 0 3 Jumlah 695 31 147 42 126 1041 Source: Family Health Development Division
Figure 55 Status Of Ambulance, 2019
Source: Family Health Development Division
Table 35 and Figure 36 show the years of usage of the ambulance in health clinics. 18 percent of the current ambulance fleet are more than 10 years in use. Nevertheless, some of these ambulance are still functioning.
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Table 35 Number Of Ambulance By Years Of Usage, 2019
STATES NUMBER OF <10 >10 TOTAL HEALTH YEARS YEARS CLINIC Perlis 10 8 0 8 Kedah 61 48 15 63 Penang 33 15 1 16 Perak 88 60 26 86 Selangor 80 77 10 87 W.P. Kuala Lumpur/ Putrajaya 19 19 2 21 N. Sembilan 50 27 12 39 Melaka 32 25 0 25 Johor 96 79 24 103 Pahang 86 48 14 62 Terengganu 51 44 9 53 Kelantan 94 76 4 80 Sabah 110 84 28 112 Sarawak 215 107 9 116 W.P.Labuan 2 1 1 2 Jumlah 1027 718 155 873 Source: Family Health Development Division
Figure 56 Percentage Of Ambulance By Years Of Usage, 2019
Source: Family Health Development Division There was no procurement of ambulance in 2019. Under the Rolling Plan 4, 11th Malaysia Plan (RP4 11MP), 500 ambulance including Type A & B, 4 WD ambulance and Patient Transporter
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Special Vehicle was submitted to the Planning Division. 290 ambulances (Type B) was approved for the health clinics.
Currently, a study on the Economic Evaluation of Ambulance Services in MOH facilities together with the Medical Development Division and Institute Health System Research is in progress.
Health clinics on the islands and remote areas accessible by rivers are equipped with boat ambulance (Table 36). There are 44 boat ambulances of which 2 are rented from a private company.
Table 36 Status Of Boat Ambulance At Health Clinic, 2019
STATE STATUS Rent Good % Repair % Proses BER % BER % Total Good Perak 1 Selangor 1 Pahang 11 84.6 2 15.4 0 0.0 0 0.0 13 0 Terenggan 1 50.0 1 50.0 0 0.0 0 0.0 2 0 u Kelantan 6 100.0 0 0.0 0 0.0 0 0.0 6 0 Sarawak 8 72.7 1 9.1 2 18.2 0 0.0 11 0 Sabah 8 80.0 0 0.0 2 20.0 0 0.0 10 0 Malaysia 34 81.0 4 9.5 4 9.5 0 0.0 42 2 Source: Family Health Development Division
7.3 Government Integrated Radio Network The Government Integrated Radio Network (GIRN) is important in communication to ensure that information can be delivered smoothly, correctly and securely. The MOH Communication Radio System is based on the Government Integrated Communication System, which is coordinated and regulated by the National Security Council under the Prime Minister's Department. GIRN is a network that shares infrastructure, but maintains the autonomy and independence of each agency. MOH Communication Radio Operation Procedures guideline is used as a reference document for health staff to operate communication radio equipment more effectively and efficiently.
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Operating the communication radio requires systematic and comprehensive training to build the attitude, skills and knowledge that is required for terminal users. Health staff including ambulance drivers are trained in the use of GIRN. Each MECC is responsible for conducting training to users on a regular basis with the collaboration of the communication concessionaires.
7.4 Disaster Floods are the most common natural threat in Malaysia and health facilities are prepared to handle this disaster, which usually occurs at the end of the year. The facilities have developed detailed Plan of Action to manage the flood situations. Simulation exercises are conducted at the district health office and health clinics. Preparedness for floods include: i. Identify high risk health facilities ii. Identify high-risk cases (pregnant women, hemodialysis etc.) iii. Identify temporary disaster evacuation centers iv. Provision of a temporary clinic at a disaster evacuation center v. Ensure adequate medical equipment and drugs vi. Provision of non-medical equipment (gensets, boats, communication equipment etc) vii. Update contact numbers of health staff viii. Flood preparedness training/ briefing for health personnel
7.5 Treatment Charges The Finance Division in MOH is constantly updating circulars and guidelines for charges in medical treatment for citizens and non-citizens. FHDD provides feedback on treatment charges related to primary health care facilities. Citizens are subject to the Fees Act 1951, Fees (Medical) Order 1982, Fees (Medical) (Amendment) Order 2017. For non-citizens, charges are imposed in accordance with the Circular from the Secretary General of the Ministry of Health Malaysia No. 2/2019 - Guidelines for the Implementation of the Fee (Medical) Order 2014 dated 8 April 2019.
7.6 Non-MOH Specialist Service At Health Clinic Non-MOH specialist from the private universities are allowed to provide health service in the health clinics. However, they need to obtain yearly written permission from the Director General of Health. This was decided during the Ministry of Health Policy Planning and Development Committee (JDPKK) No.1 / 2002 on 21 February 2002 and Post Cabinet Meeting on 27 February 2002.
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During 2019, 13 lecturers from Penang Medical College provided services in various health clinics in Penang (Table 10).
Table 37 Number Of Non-Moh Specialist Providing Service In Health Clinic, 2019 NUMBER OF HEALTH CLINIC SPECIALITY SPECIALIST KK Air Itam, Penang 2 Family Medicine KK Bandar Baru Air Itam, Penang 3 Family Medicine Family Medicine (1) KK Jalan Perak, Penang 3 Psychiatry (2) Family Medicine (1) KK Bayan Baru, Penang 2 Psychiatry (1) KK Tanjung Bungah, Penang 1 Family Medicine KK Jalan Macalister, Penang 2 Psychiatry (2) Source: Family Health Development Division
7.7 Supervisiory Visits Supervisory visits were made to 12 health clinics in 2019 (Table 38). The visits showed the health facilities were prepared to receive emergency cases and respond to ambulance calls. However, improvements can be made in the areas of infection control practices, increasing the use of EAS and providing training to health staff.
Table 38 Health Clinic Visited In 2019 DATE STATES DISTRICT HEALTH CLINIC Klinik Kesihatan Kalumpang 12.2.2019 Selangor Hulu Selangor Klinik Kesihatan Rasa Wilayah Klinik Kesihatan Presint 11 16.5.2019 Putrajaya Persekutuan Klinik Kesihatan Presint 14 17.5.2019 Negeri Sembilan Seremban Klinik Kesihatan Klia, Nilai 24.5.2019 Selangor Sepang Klinik Kesihatan Salak 28.5.2019 Negeri Sembilan Seremban Klinik Kesihatan Nilai 24.7.2019 Perak Muallim Klinik Kesihatan Tanjung Malim Klink Kesihatan Lurah Bilut 7.10.2019 Bentong Pahang Klinik Kesihatan Telemong 8.10.2019 Temerloh Klinik Kesihatan Kuala Krau 85
DATE STATES DISTRICT HEALTH CLINIC Klinik Kesihatan Bandar Mentakab Source: Family Health Development Division
7.8 Human Rights And Health Issues This sector collaborates with other divisions in providing feedback on health issues related to Anti-Trafficking in Persons and Anti-Smuggling of Migrants, migrant health and refugee health seeking medical care at primary health care facilities.
Health services are provided to all in Malaysia without discrimination. Patients with life- threatening conditions regardless of their citizenship status are provided with emergency treatment without having to pay an initial deposit. The provision of health services and treatments in government facilities are based on charges stipulated in the Fees Act 1951 and the Fees (Medical) (Cost of Services) Order 2014.
Feedback was provided for the Resolution to Promote the Health of Women Migrant Workers at the 10th ASEAN Inter-Parliamentary Council Caucus Meeting in June 2019 in Kuala Lumpur. This sector is directly involved in the ASEAN Framework on Health Coverage for Migrants Documentation including Migrant Workers and Special Population held on 10-12 September 2019 in Surabaya, Indonesia.
7.9 Primary Health Care Performance Initiative Primary Health Care Performance Initiative (PHCPI) invited Malaysia to participate in the Vital Signs Profile (VSP) as one of the ‘Trailblazer’ countries. VSP is a parameter to help the country evaluate the overall performance of the primary health care system. VSP Malaysia was launched at the Global Health Conference on Primary Health Care in Astana in October 2018 and was attended by the Director General of Health. The second part of the VSP is the Progression Model where it evaluates the capacity of Primary Health Care systematically. Progression model consists of 33 parameters, where each parameter needs to be matched to the performance category. A workshop was held in August 2019 to discuss these parameters with participants from the state, district, private sector and health clinic advisory panel. Malaysia is in the process of analyzing the parameters.
7.10 Asean Cluster 3 This sector is involved in the Technical Working Group for the development of ASEAN Recommendations For Quality Healthcare in Primary Care. It is one of the activities of ASEAN Health Cluster 3: Strengthening Health System and Access to Care. The recommendations focus
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on three aspects, namely health facilities, human resources and service packages and will be used by ASEAN countries to improve their primary health care. A workshop involving a WHO consultant together with representatives from ASEAN countries was held from 19 to 23 August 2019 at Geno Hotel Shah Alam, Selangor to analyze and collate information on primary health care from all ASEAN countries.
8 CHILD HEALTH SERVICES
Child health services is part of the Maternal and Child Health Services that began in the 1960s. It is one of the core health services provided to all newborns and children up until the age of 6 years. Services provided are based on public health principles of prevention which are health promotion and specific protection, early detection and prompt treatment, disability limitation and rehabilitation.
The main function of Child Health Sector in the Family Health Development Division is to plan, monitor, implement and evaluate the effectiveness of perinatal, neonatal and child health programmes.
8.1 Attendance to Health Facilities
Scheduled routine visits to the health clinics for health services by newborns and children up to six years, is important for the monitoring of child general well-being, growth and development. In addition, children also undergo oral health checkup, immunisation, M-Chat screening and visual assessment. At the age of 1 month, 18 months and 4 years every child will be examined by a medical officer.
Child attendances to the health clinics is an indicator that is closely monitored in order to understand public acceptance of the service provided and to ensure children living within the health clinic’s operational area, receives the appropriate services.
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Figure 57
Proportion of Children According to Age Group Attending Health Facilities, 2015-2019p
Source: Health Informatics Centre, Ministry of Health Malaysia
The target for child attendance to health clinic is 75 per cent of children aged below 1 year, 60 per cent of toddlers aged 1-4 years and 20 per cent of pre-school children aged 5-6 years. Since 2016, between 75 and 76 per cent of children under 1 year of age has attended government health clinics. This is expected as the deliveries in public facilities are around 80-85 per cent per year. Figure 57 also shows that since 2016 there has been an increase of attendances among children aged 5-6 years.
In 2016, the Child Health Sector developed and implemented guidelines to aid medical officers do proper assessment and examination of 4 year old children. The guideline also serves to empower parents to adhere to routine health and developmental assessment, prior to admission to pre-school. In 2018, the target for attendance among toddlers 1-4 years was increased from 40 per cent to 60 per cent. During supervisory visits to health clinics, toddler attendance was still found to be low due to the lack of awareness among healthcare workers. Following this, a series of training of trainers was held in 2019 (Refer Activity 1)
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Figure 58
Average Number of Child Attendance to Health Clinic, 2015-2019p
Source: Health Informatics Centre, Ministry of Health Malaysia
The average number of visits per child for routine examination is 8 visits for children aged less than 1 year, 9 visits for children age 1-4 years and 2 visits for pre-school children. Minimum number of visits for children less than 1 year is 7 times, 4 times for toddlers aged 1-4 years and 2 times for pre-school children. Figure 58 shows average number of child attendance to the health facility. The average number of attendances to health clinic for children age < 1 year and age 1-4 years old has increased since 2015 while the average number of clinic attendance for pre-school age has meet the target.
8.2 G6PD Deficiency Screening Programme
Newborn screening programme began in 1985 with screening for G6PD deficiency implemented nationwide, to reduce the number of severe neonatal jaundice cases.
Table 39 shows percentage of newborn babies delivered in government facilities detected to have G6PD deficiency. Among the registered live birth in government facilities, percentage of newborn screened for G6PD deficiency increased from 79.9 per cent in 2015 to 90.3 per cent in 2019, whilst those detected with G6PD deficiency range between 1.16 to 1.4 per cent. The data is only from government health facilities and covers 85-88 per cent of total live birth as shown in Table 40.
Confirmatory test is required to get the actually number of G6PD deficiency cases, however this test is not readily available nationwide.
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Table 39
Coverage of G6PD Deficiency Screening and G6PD Deficiency Cases, 2015-2019p
Year Registered Live Birth at No. of Cases Percentage No. of G6PD Percentage Government Facilities Screened Screened (%) Deficiency of G6PD Cases Deficiency Cases (%)
2015 448,422 390,525 79.9 4,529 1.16
2016 446,593 396,266 88.7 4.739 1.20
2017 447,658 401,607 89.7 5,732 1.43
2018 446,598 401, 617 89.9 5,258 1.31
2019p 437,602 394,397 90.3 5,686 1.44
Source: Health Informatics Centre, Ministry of Health Malaysia
Table 40
Percentage of Total Birth Live Birth Delivered in Government Health Facilities, 2015-2019p
Year Live Birth Birth registered at Percentage of birth (DOSM) government health registered at government facilities health facilities
2015 511,865 448,422 87.6.%
2016 521,136 446,593 85.7%
2017 508,203 447,658 88.0%
2018 508,685 446,598 87.8%
2019p 501,945 437,602 87.2%
Source: Health Informatics Centre, Ministry of Health Malaysia
8.3 National Congenital Hypothyroidism Screening Programme
Newborn screening programme expanded to include screening for Congenital Hypothyroidism in 1998. Thus far, 1,278 clinics and hospital from both government and private sectors have implemented this programme. Increasing the number of participating facilities is important to ensure that all newborn are screened. Two indicators closely monitored are percentage of newborn screened and percentage of positive cases treated within 14 days of life. More than 98 per cent of newborn have been screened and almost all positive cases are treated within 14 days, an increase of 51 per cent within 10 years Figure 59 90
Figure 59
Percentage of Cases Received Treatment Within 14 Days of Life, 2008-2019p
Source: Family Health Development Division
The National Screening Programme for
Congenital Hypothyroidism guideline was first published in 2000 and since then has been reviewed in 2011 and 2018.
The latest review is in line with the updated Paediatric Protocol, including the change of cut off value for TSH level where definition of normal value has been reduced to 20mU/L.
8.4 National Quality Assurance Program for Neonatal Jaundice
Severe Neonatal Jaundice (SNNJ) may lead to kernicterus which could end in death or disability. In order to prevent this, the rate of severe neonatal jaundice has been identified as an indicator to be monitored. Rate of severe neonatal jaundice has been targeted at < 50 cases in every 10,000 live birth.
Since 2015, rate of severe neonatal jaundice cases has been less than 50 per 10,000 live birth. Among the various measures taken to ensure that the rate of SNNJ remains low, include increasing awareness and knowledge among parents and competency in early detection of jaundice among healthcare personnel.
Table 41
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Severe Neonatal Jaundice Rate (per 10,000 LB), 2015-2019p
Year Estimated Cycle 1 Cycle 2 Yearly Live Birth Number Rate Number Rate Number Rate
2015 511, 865 1157 45.21 1286 50.25 2443 47.73
2016 521,136 1180 45.26 1114 42.75 2294 44.02
2017 508,203 854 33.61 824 32.43 1678 33.02
2018 508,685 782 30.75 876 34.44 1658 32.59
2019p 501,945 690 27.49 990 39.45 1680 33.47
Source: Family Health Development Division, Ministry of Health Malaysia *Cycle 1: January to June, Cycle 2: June to December
8.5 National Immunisation Programme Program
The National Immunisation Programme has been implemented for more than 60 years in Malaysia and has successfully reduced the under-5 morbidity and mortality caused by vaccine preventable disease. Currently there are 10 types of vaccines provided against 12 vaccine preventable diseases. Malaysia has achieved the polio free status in 2000, however in December 2019 there was a polio outbreak in Sabah.
Immunisation coverage for selected vaccines
BCG, DTaP-IPV/Hib 3rd dose, Hepatitis B 3rd dose and MMR 1st dose (MCV-1) and MMR 2nd dose are among performance indicators closely monitored under the National Immunisation Programme. The DTaP-IPV/Hib 3rd dose coverage has been an indicator for SDG-UHC since 2016 and key performance indicator for the health minister since 2019, while coverage for MMR among children aged 1 to < 2 years is an indicator under the Ministry’s Strategic Plan. Immunisation coverage for BCG, DTaP-IPV/Hib 3rd dose, Hepatitis B 3rd dose and MMR 1st dose (MCV-1) is as shown in Table 42.
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Table 42
National Immunisation Coverage, Malaysia 2010-2019p
Year 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019(p)
BCG 99 98.7 98.7 98.5 98.6 98.5 98.3 98.5 98.4 98.5
DPT- 94.28 99.5 99.7 96.9 96.7 99.0 97.9 98.9 100.2 96.85 IPV//HiB 3rd dose
Hep B 3rd 82.57 97.1 98.07 96.3 96.3 99.2 97.9 98.2 99.8 95.88 dose
MMR 1st 96.10 95.2 95.4 95.2 92.0 93.1 94.3 93.5* 96.6* 96.64* dose **
MMR 2nd 88.80** 87.75** 97.67 * dose
Source: Health Informatics Centre, Ministry of Health Malaysia
Denominator: *Estimated Live Birth
** Estimated Children Aged 1- < 2 years
MMR 1st dose coverage: Since 2017, coverage for MMR 1st dose is at age 9 month, while data before 2017 shows coverage of MMR 1st dose at age 12 months.
MMR 2nd dose coverage: Prior to 2017, coverage is among children below 7 years (documented in this report under school health service) Immunisation Coverage for 2019
Figure 60 shows immunisation coverage for year 2019. Immunisation coverage that has achieved national target of > 95 per cent are BCG, Hepatitis B 3rd dos, DTaP/IPV/Hib 3rd dose , MMR 1st and 2nd dose and JE 1st dose.
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Figure 60
Immunisation Coverage for Primary Vaccines, 2019p
Source: Health Informatics Centre, Ministry of Health Malaysia
Denominator: Estimated live birth from Department of Statistics Malaysia (501,945)
BCG Immunisation
Immunisation coverage over the past 10 years has achieved more than 95 per cent showing that BCG vaccine is widely given at birth. Monitoring the BCG coverage was also made possible following the systematic data collection in all states since the implementation of Tuberculosis Information System in 2010.
DTaP-IPV/Hib Immunisation
Since 2011, immunisation coverage for 3rd dose has maintained more than 95 per cent as shown in Figure 61.
Figure 61
Immunisation Coverage DTaP-IPV/Hib, 2009-2019p
Source: Health Informatics Centre, Ministry of Health Malaysia 94
Despite the high coverage of more than 95 per cent for 3rd dose DTaP-IPV/Hib, polio outbreak occurred in Sabah in December 2019. Among the contributing factors to the re-emergence of polio cases in Malaysia include:
● Small groups of non-citizen children were not registered with the National Registration Department. These unregistered children were missed out in the denominator for calculation of immunisation coverage. Thus, although the coverage of polio in Sabah is more than 95 per cent, it does not show the actual coverage. ● The non citizen children who were reported unvaccinated had poor nutritional and health status thus increasing their risk of contracting vaccine preventable diseases.
Hepatitis B Immunisation
Immunisation coverage for 3rd dose Hepatitis B in 2019 was 95.8 per cent, exceeding the national target. However, there are still issues to be addressed with regards to Hepatitis B vaccination:
● Immunisation coverage reported for birth dose (1st dose) is below the targeted 95 per cent. World Health Organisation recommends the first dose to be given within 24 hours of birth to prevent maternal to child transmission of hepatitis, and also urges countries to ensure coverage for 1st dose Hepatitis B maintains above 95 per cent. ● There is significant difference between immunisation coverage for Hepatitis 1st dose and 3rd dose even using the same denominator (Figure 62). This is due to different mechanisms in data collection and data reporting from the hospital including private facilities.
Figure 62
Immunisation Coverage Hepatitis 1st dose and 3rd dose, 2009-2019p
Source: Health Informatics Centre, Ministry of Health Malaysia 95
MMR Immunisation
● The MMR immunisation schedule underwent a change beginning 1st April 2016 involving all children born after 1st July 2015. Prior to 1st April 2016, the first dose was given at 12 months and the 2nd dose at 7 years. Beginning 1st April 2016, the 1st dose is given at 9 months whilst the 2nd dose at 12 months. ● Prior to the change in the schedule, coverage for immunisation 1st dose MMR used estimated number of children age 1 - < 2 years as the denominator and the coverage from 2014 until 2017 was below 95 per cent. Following the new schedule in 2016, the coverage for 1st dose MMR at 9 month of age used estimated live birth as the denominator. Immunisation coverage for 1st dose MMR has achieved 96.6 per cent in 2018 and 2019. ● From 2016 until 2018, immunisation coverage for 2nd dos of MMR at 12 months was calculated using estimated population of children age 1 - < 2 years as the denominator. Beginning 2019, estimated live birth is used as denominator to calculate the coverage for 2nd dose MMR. Rationale for using estimated live birth as the denominator to calculate coverage for MMR 2nd dose are as follows:
− The gap between 1st and 2nd dose for MMR is only 3 months, thus using estimated live birth of the previous year as a denominator to calculate the 2nd dose MMR given at 12 months is more accurate. − Data shows that the number of children receiving immunisation at 9 months and 12 months are the same, thus coverage of both doses should be similar. However, coverage of immunisation at 12 months is far lower due to the use of estimated children age 1 - < 2 years as the denominator. By using estimated live birth as the denominator, calculation of the coverage is more accurate.
Table 43
Differences in MMR Dose 2 Coverage using Estimated Live Birth and
using Estimated Children Age 1- < 2 years
Year Immunisation Coverage Immunisation Coverage
at 9 Months at 12 Months
Total children Immunisation Total children Immunisation Immunisation age 9 months coverage of MMR age 12 months coverage of MMR coverage of MMR received given at 9 months received given at 12 months given at 12 months immunisation (denominator: immunisation (denominator: (denominator: estimated live birth) estimated children age estimated live birth) (%) 1-< 2 years) (%) (%)
2017 475228 93.51 489033 88.79 96.23
2018 488666 96.06 496312 87.75 97.57
2019 485088 96.64 490275 86.62 97.68
Source: Health Informatics Centre, Ministry of Health Malaysia 96
Since 2016, estimated population of children aged 1 - < 2 years has been far exceeding the estimated number of live births the previous year. Figure 63 shows that the number of estimated live births has declined from 2014 to 2019. However, the number of children age 1 - < 2 years shows an increasing trend during this period. The difference between the two, increased every year and the difference between estimated number of children aged 1-<2 years in 2019 exceeds live birth in 2018 by 64,000 children.
Figure 63
Trend of Estimated Live Birth, Estimated Children age 1 - < 2 years
and Differences of Birth Cohort, 2014-2019
Estimated live birth Estimated children age 1 - < 2 Differences of Birth Cohort years
Source: Health Informatics Centre, Ministry of Health Malaysia
Table 44
Immunisation Coverage for MMR 1st and 2nd dose, 2019
1st Dose 2nd Dose
State Total Denominator Coverage Total Denominator Coverage immunisation (%) immunisation (%) LB 2018 LB 2018 given given (DOSM) (DOSM)
Perlis 3961 4371 90.62 3,989 4371 91.26
Kedah 32619 35643 91.52 32,642 35643 91.58
Pulau 21355 20705 103.14 23,032 20705 111.24 Pinang
Perak 32515 33869 96.00 32,519 33869 96.01
WP Kuala 26755 24235 110.40 26,198 24235 108.10
97
Lumpur
WP 2987 2400 124.46 3,047 2400 126.96 Putrajaya
Selangor 103661 102125 101.50 110,684 102125 108.38
Negeri 18035 18177 99.22 17,909 18177 98.53 Sembilan
Melaka 14694 14388 102.13 14,545 14388 101.09
Johor 59929 61084 98.11 58,965 61084 96.53
Pahang 27278 27006 101.01 26,761 27006 99.09
Terengganu 25389 28242 89.90 24,670 28242 87.35
Kelantan 28104 38360 73.26 27,749 38360 72.34
WP Labuan 2090 1691 123.60 1,975 1691 116.79
Sabah 50190 53025 94.65 49,609 53025 93.56
Sarawak 35526 36624 97.00 35,981 36624 98.24
MALAYSIA 485088 501945 96.64 490275 501945 97.68
Source: Health Informatics Centre, Ministry of Health Malaysia In areas where population mobility between states is minimal between ages of 9 month and 12 months, the differences in the total number of 1st dose and 2nd dose in each state should be minimal. Table 44 shows the difference in the number of injections given between 1st and 2nd dose, where the 2nd MMR exceeds 1st dose by 5,187 (1.07 per cent.). States showing 2nd dose higher than 1st dose can be attributed to the collection of data from private sector. The districts involved are Timur Laut in Pulau Pinang and Petaling in Selangor.
States showing number of 2nd dose given less than 1st dose by more than 500 doses, include Johor, Pahang, Terengganu, Kuala Lumpur and Sabah. While the states of Perlis, Kedah, Perak and Putrajaya showed no differences between the two doses. Mobility between Putrajaya, Selangor and Kuala Lumpur for the immunisation is expected. The states of Terengganu, Kelantan, Kedah, Perlis and Sabah did not achieve the target coverage of 95 per cent for 2nd dose MMR.
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Immunisation Coverage by State, 2015-2019p
Figure 64
BCG Immunisation Coverage by State, 2015-2019p
Source: Health Informatics Centre, Ministry of Health Malaysia
Figure 65
Hepatitis B 3rd Dose Immunisation Coverage by State, 2015-2019p
Sour ce: Health Informatics Centre, Ministry of Health Malaysia
99
From 2015 until 2019, two states namely Kedah and Kelantan, did not achieve the coverage target of > 95 per cent.
Figure 66
DTaP/IPV/Hib 3rd Dose Immunisation Coverage by State, 2015-2019p
Sou rce: Health Informatics Centre, Ministry of Health Malaysia
From 2015-2019, Kedah and Kelantan failed to achieve the coverage target of > 95 per cent.
Figure 67
MMR 1st Dose Immunisation Coverage by State, 2015-2019p
Source: Health Informatics Centre, Ministry of Health Malaysia
100
At the start of the implementation of the new schedule in 2016, the uptake of 1st dose MMR at 9 months was below target, however in both 2018 and 2019 the coverage was > 95 per cent.
Vaccine Refusal
Number of vaccine refusals have slightly reduced from 1365 cases in 2018 to 1337 cases in 2019. States with the highest number of cases is Perak followed by Kedah and Selangor
Figure 68
Source: Family Health Development Division
Top three reasons for vaccine refusal are:
i. Issue of halal and haram ii. Doubting the content of vaccines iii. Prone for traditional medicine compare to vaccination
8.6 Mortality Rates for Deaths Among Neonatal, Infant and Children Under 5 Years
The Sustainable Development Goals (SDGs) for child mortality, aims to end preventable deaths of newborns and children under 5 years of age by 2030, with all countries aiming to reduce neonatal mortality to at least as low as 12 deaths per 1,000 live births and under-5 mortality to at least as low as 25 deaths per 1,000 live births.
Malaysia has already achieved the SDG target set in 2016 and will continue its efforts to further reduce the under-5 mortality rate. For better planning of appropriate interventions, data on deaths and cause of preventable death is important. This requires a systematic reporting system as well as method for verification. 101
Under-5 mortality reporting system
In 1997, Maternal Health Sector developed the Perinatal Mortality Reporting System for reporting of all stillbirths and mortality among newborns aged 0-27 days. One of the targets for Millennial Developmental Goals (MDG) was reduction of Under-5 Mortality by two thirds. A national level committee was set up then to plan, implement and monitor activities towards achieving this target. One suggestion proposed in 2009 was the development of a system for reporting of deaths among children under 5 years.
Beginning July 2011, child mortality notification and reporting system for ages 28 days to 5 years was introduced and managed by the Child Health Sector. Later, in October 2012, the perinatal reporting system was adopted by the Child Health Sector. The two reporting systems was combined and a new and improved system was introduced, namely the Stillbirth and Under 5 Mortality Reporting (SU5MR) System and implemented from July 2013 to this date. All deaths among children under 5 years of age and stillbirth must be notified and reported, including deaths occurring in private hospitals and outside hospitals.
The objective of the SU5MR is to improve and standardize the reporting of all still births and under-5 deaths. The system ensures that all deaths are reported and investigated within the stipulated time, as well as analyzed at the district, state, and national levels. The output of the system is verified data that can be used as a database for stillbirth and under-5 deaths. The output of the system will assist in detecting shortfalls as well as interventions needed. The system also has a procedure for monitoring and planning strategic interventions.
Monitoring under-5 mortality
In line with the introduction of the SU5MR, the Under-5 Mortality Technical Committees were established at the district and state levels. All cases are discussed at the district and state levels before the full report is sent to the FHDD. At the national level, FHDD is the secretariat for two national technical meetings namely the National Data Coordinating Meeting and the National Mortality Report Review Meeting.
The National Data Coordinating Meeting is held to finalise the mortality data sent to FHDD and is attended by state coordinators for the reporting system. The National Mortality Report Review Meeting is attended by state Family Health officers and from relevant Divisions in MOH to discuss mortality cases that require national level interventions.
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Figure 69
Flow Chart for Stillbirth and Under 5 Mortality Reporting (SU5MR) System
Stillbirth or Under 5 deaths (0 - <5 years old)
Hospital coordinator reports death using notification format to the nearest District Health Office (DHO) within 24 hours from time of death
District Office Coordinator approves and sends notification form to State Coordinator within 24 hours from time of death
OR
Forwards notification form to relevant DHO according to residence
The State coordinator sends the notification form to the Family Health Development Division (FHDD) by fax or email: [email protected] after verification
Medical officer or specialist (hospital/ health clinic) at place of death
fills the SU5MR-1/2012 format and submits to DHO
DHO will review and complete the SU5MR-I / 2012 form before
submitting to State Office
The State Office will review, complete and verify the information in the SU5MR-I / 2012 form and submit it to the FHDD
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Networking and Cooperation with Other Agencies
FHDD has held several discussions with the Royal Malaysia Police (PDRM) to increase the number of medically certified deaths among children under 5 years. On 25th June 2015, PDRM issued an official letter from the Director of the Criminal Investigation Department . 5/2015 entitled Procedure for Determining the Cause of Death of Children Under 5 Years. This letter instructs police officers investigating death cases outside the medical facility to inform the nearest hospital / clinic and get assistance to determine the cause of death before issuing a burial permit.
Since 2015, FHDD has provided input to the Department of Statistics Malaysia (DOSM) based on the annual findings of the SU5MR system for verification before reports of the Vital Statistics is published. The issue published by DOSM will be used as reference material for various parties.
As the target of SDG 2030 aims to end preventable deaths among children under 5 years, in 2017 FHDD in collaboration with Pediatricians published the Guideline on Classification of Under 5 Deaths into Preventable & Non-Preventable Deaths. The guideline aims to standardize and assist in determining the classification of preventable deaths.
FHDD together with pediatricians are currently auditing all 2016 under-5 deaths to identify the actual percentage of preventable deaths by state. The result of this study will be the basis for setting the targets of SDG 2030 by states.
Numbers and Rates for Stillbirth, Perinatal, Neonatal, Infant and Under-5 Mortality
The official data for mortality rates in Malaysia is reported by the Department of Statistics. The main aim of the SU5MR System data was to identify causes of death, including the road leading to death, to assist in planning interventions for improvement of the health system.
Number of deaths and mortality rates for both stillbirths and under-5 deaths reported by the Department of Statistics and FHDD (through the SU5MR System) are slightly different, where the number reported by the FHDD is higher. The discrepancy between these two data is due to the different nature of data collection, definition used and the limitations due to local regulations.
One example is number of stillbirths, where the Department of Statistics uses the WHO definition of ‘a baby born with no signs of life at or after 28 weeks gestation’ to enable global comparisons, while FHDD under the SU5MR System uses the cutoff of 22 weeks and above to further improve health services. Both DOSM and FHDD will continue to work on streamlining the data.
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During the process of coordinating and refining data by the Department of Statistics, reports of death provided by FHDD will be matched with that from Registration Department, such as date of birth & death, identity card number and mother's name. The figure and table below show the mortality rate of children under 5 years old based on the Notification and Reporting System of Deaths and Deaths of Children Under 5 (SU5MR) by FHDD and the Department of Statistics Malaysia.
Figure 70
Neonatal, Infant and Under 5 Mortality Rates, Malaysia
2014 2015 2016 2017 2018 2019ᴾ
Under 5 Mortality Rate 9.47 9.9 9.85 9.78 10.11 8.68
Infant Mortality Rate 7.82 8.19 8.12 8.1 8.36 7.31
Neonatal Mortality Rate 5.15 5.43 5.25 5.4 5.54 4.85
Source: Family Health Development Division
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Table 45
Difference in Mortality Rates for Neonatal, Infant and Children Under-5 Years,
Data from SU5MR System and Department of Statistics, 2014-2019p
Data Source 2014 2015 2016 2017 2018 2019ᴾ
Under-5 SU5MR 9.47 9.9 9.85 9.78 10.11 8.68 Mortality Rate System
Department 8.3 8.4 8.1 8.4 8.8 - of Statistics
Infant Mortality SU5MR 7.82 8.19 8.12 8.1 8.36 7.31 Rate System
Department 6.7 6.9 6.7 6.9 7.2 - of Statistics
Neonatal SU5MR 5.15 5.43 5.25 5.4 5.54 4.85 Mortality Rate System
Department 4.2 4.3 4.2 4.4 4.6 - of Statistics
Source: Department of Statistics and Family Health Development Division
2019ᴾ: Data cleaning and streamlining yet to be implemented
Mortality trends for neonatal, infant and under-5 mortality have plateau since 2000 to 2018 (Figure 70). Under-5 mortality rate for 2018 showed a slight increase compared to 2017. Among the contributing factors is the increase in number of reported deaths from 4,295 to 4,427 and the decrease of livebirths from 508,685 in 2017 to 501,945 in 2018 (DOSM). States of Terengganu and Federal Territory of Kuala Lumpur had the lowest mortality rates i.e. 7.3 per 1000 livebirths, whilst Sabah recorded the highest at 12.7 per 1000 livebirths.
Neonatal mortality (0-28 days) contributes to 52.4 per cent (2,321 cases) of the total Under 5 mortality, while the mortality among infants 28 days to less than 1 year contributes to 29.4 per cent (1,301 cases) and death among toddlers 1-4 years make up 18 per cent (805 cases) of total deaths. Majority of neonatal deaths are not preventable and the main causes are congenital malformation and conditions from perinatal period. Preventable deaths for example injury and infections occur among children 28 days to under 5 years. To achieve the SDG 2030 target, the focus of the programme will be to reduce preventable deaths due to injury and infection.
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Tables 46, 47, 48, 49 and 50 show details of Under-5 Mortality, Infant Mortality, Neonatal Mortality, Perinatal Mortality and Stillbirth by numbers and rates according to states for the years 2014 to 2018 published by Department of Statistics.
Table 46
Under-5 Mortality Number & Rate by State, 2014-2018
Under 5 Mortality
State 2014 2015 2016 2017 2018
Number Rate Number Rate Number Rate Number Rate Number Rate
Perlis 36 8 38 8.8 30 6.8 30 6.7 45 10.3
Kedah 287 7.9 288 7.8 308 8.6 268 7.3 286 8
P. Pinang 160 7 166 7.5 174 8 150 7 158 7.6
Perak 284 7.8 295 8.1 308 8.6 296 8.5 284 8.4
WP Kuala 192 7.1 167 6.5 191 7.4 190 7.7 177 7.3 Lumpur
WP 39 12.7 27 9.4 28 10.9 23 9.1 27 11.3 Putrajaya
Selangor 703 6.5 700 6.5 776 7.4 752 7.2 797 7.8
N. Sembilan 150 8 154 8.4 135 7.5 179 9.9 189 10.4
Melaka 104 7.1 102 7 114 7.9 114 7.9 120 8.3
Johor 445 7.4 517 8.5 534 9 503 8.2 515 8.4
Pahang 270 9.4 273 9.7 254 9.2 257 9.3 244 9
Terengganu 259 9.6 265 9.6 236 8.6 210 7.5 207 7.3
Kelantan 395 10.1 315 8.1 367 9.5 363 9.3 343 8.9
WP Labuan 17 9.1 19 9.7 17 9.7 12 7.1 17 10.1
Sabah 740 12.9 766 14 377 7.2 652 12.4 671 12.7
Sarawak 303 7.4 276 6.9 284 7.5 296 7.9 347 9.5
MALAYSIA 4384 8.3 4368 8.4 4133 8.1 4295 8.4 4427 8.8
Source: Department of Statistics Malaysia (DOSM)
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Table 47
Infant Mortality Number and Rate by State, 2014-2018
Infant Mortality
State 2014 2015 2016 2017 2018
Number Rate Number Rate Number Rate Number Rate Number Rate
Perlis 34 7.5 35 8.1 26 5.9 25 5.6 39 8.9
Kedah 230 6.3 241 6.6 254 7.1 215 5.9 229 6.4
P. Pinang 128 5.6 140 6.3 141 6.5 125 5.8 133 6.4
Perak 227 6.2 234 6.4 245 6.9 242 6.9 223 6.6
WP Kuala 167 6.2 140 5.4 159 6.2 160 6.5 150 6.2 Lumpur
WP 31 10.1 22 7.7 21 8.2 21 8.3 22 9.2 Putrajaya
Selangor 573 5.3 572 5.3 643 6.1 620 6 662 6.5
N. Sembilan 129 6.9 128 6.9 116 6.4 148 8.2 162 8.9
Melaka 84 5.8 80 5.5 100 6.9 95 6.6 110 7.6
Johor 368 6.1 440 7.3 443 7.4 413 6.8 422 6.9
Pahang 213 7.4 216 7.7 204 7.4 205 7.4 197 7.3
Terengganu 213 7.9 218 7.9 199 7.2 173 6.2 173 6.1
Kelantan 319 8.1 261 6.7 298 7.7 302 7.7 288 7.5
WP Labuan 15 8 18 9.2 14 8 12 7.1 16 9.5
Sabah 576 10 614 11.2 298 5.7 502 9.6 534 10.1
Sarawak 236 5.7 223 5.6 229 6 238 6.3 262 7.2
MALAYSIA 3543 6.7 3582 6.9 3390 6.7 3496 6.9 3622 7.2
Source: Department of Statistics Malaysia (DOSM)
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Table 48
Neonatal Mortality Number and Rate by State, 2014-2018
Neonatal Mortality
State 2014 2015 2016 2017 2018
Number Rate Number Rate Number Rate Number Rate Number Rate
Perlis 22 4.9 23 5.3 17 3.9 11 2.5 28 6.4
Kedah 164 4.5 151 4.1 171 4.8 140 3.8 151 4.2
P. Pinang 80 3.5 103 4.6 101 4.6 83 3.9 89 4.3
Perak 143 3.9 143 3.9 157 4.4 161 4.6 150 4.4
WP Kuala 99 3.7 79 3.1 105 4.1 94 3.8 98 4 Lumpur
WP 14 4.6 12 4.2 14 5.4 12 4.8 12 5 Putrajaya
Selangor 342 3.1 354 3.3 380 3.6 386 3.7 422 4.1
N. Sembilan 83 4.4 88 4.8 78 4.3 103 5.7 111 6.1
Melaka 54 3.7 32 4.6 60 4.2 60 4.2 71 4.9
Johor 242 4 285 4.7 287 4.8 274 4.5 265 4.3
Pahang 118 4.1 131 4.7 119 4.3 130 4.7 125 4.6
Terengganu 156 5.8 142 5.1 120 4.4 114 4.1 118 4.2
Kelantan 216 5.5 169 4.3 193 5 198 5.1 195 5.1
WP Labuan 10 5.3 11 5.6 9 5.1 7 4.2 12 7.1
Sabah 308 5.4 391 7.1 171 3.3 322 6.1 335 6.3
Sarawak 151 3.7 136 3.4 132 3.5 158 4.2 139 3.8
MALAYSIA 2202 4.2 2264 4.3 2114 4.2 2253 4.4 2321 4.6
Source: Department of Statistics Malaysia (DOSM)
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Table 49
Perinatal Mortality Number and Rate by State, 2014-2018
Perinatal Mortality
State 2014 2015 2016 2017 2018
Number Rate Number Rate Number Rate Number Rate Number Rate
Perlis 40 8.8 42 9.7 33 7.5 36 8.1 40 9.1
Kedah 315 8.6 296 8 294 8.1 301 8.2 283 7.9
P. Pinang 144 6.3 182 8.1 205 9.4 169 7.8 191 9.2
Perak 250 6.8 260 7.1 331 9.2 297 8.5 265 7.8
WP Kuala 164 6 159 6.1 219 8.5 223 9 194 8 Lumpur
WP 23 7.5 22 7.6 17 6.6 16 6.3 23 9.5 Putrajaya
Selangor 687 6.3 683 6.3 773 7.4 797 7.6 811 7.9
N. Sembilan 131 7 146 7.9 135 7.5 177 9.7 172 9.4
Melaka 113 7.7 101 6.9 115 7.9 121 8.4 137 9.5
Johor 414 6.8 540 8.9 543 9.1 504 8.2 576 9.4
Pahang 255 8.8 253 9 239 8.6 254 9.2 258 9.5
Terengganu 291 10.7 279 10 227 8.2 236 8.4 208 7.3
Kelantan 374 9.5 321 8.2 366 9.5 363 9.2 335 8.7
WP Labuan 9 4.8 19 9.7 14 8 15 8.8 17 10
Sabah 438 7.6 478 8.7 464 8.9 630 11.9 714 13.4
Sarawak 286 6.9 254 6.4 271 7.1 310 8.2 290 7.9
MALAYSIA 3934 7.4 4035 7.7 4246 8.3 4449 8.7 4514 8.9
Source: Department of Statistics Malaysia (DOSM)
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Table 50
Stillbirth Number and Rate by State, 2014-2018
Stillbirth
State 2014 2015 2016 2017 2018
Number Rate Number Rate Number Rate Number Rate Number Rate
Perlis 83 3.6 25 5.8 22 5 25 5.6 23 5.2
Kedah 191 5.2 177 4.8 178 4.9 195 5.3 167 4.7
P. Pinang 83 3.6 103 4.6 123 5.6 111 5.1 123 5.9
Perak 149 4.1 156 4.3 211 5.9 170 4.9 149 4.4
WP Kuala 97 3.6 97 3.7 144 5.6 147 5.9 123 5 Lumpur
WP 10 3.3 12 4.2 5 1.9 6 2.4 14 5.8 Putrajaya
Selangor 426 3.9 419 3.9 484 4.6 518 5 505 4.9
N. Sembilan 67 3.6 87 4.7 76 4.2 98 5.4 92 5
Melaka 71 4.9 65 4.4 66 4.6 71 4.9 84 5.8
Johor 238 3.9 319 5.2 322 5.4 302 4.9 374 6.1
Pahang 157 5.4 154 5.5 152 5.5 158 5.7 157 5.8
Terengganu 173 6.4 166 6 139 5 154 5.5 122 4.3
Kelantan 217 5.5 201 5.1 224 5.8 224 5.7 197 5.1
WP Labuan 4 2.1 8 4.1 8 4.5 11 6.5 9 5.3
Sabah 199 3.5 173 3.2 323 6.2 386 7.3 431 8.1
Sarawak 174 4.2 163 4.1 171 4.5 193 5.1 185 5
MALAYSIA 2277 4.3 2325 4.4 1648 5.2 2769 5.4 2755 5.5
Source: Department of Statistics Malaysia (DOSM)
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8.7 Child Health Sector: Activities in 2019
Various courses, workshop and activities have been conducted in 2019 by the Child Health Sector to improve the knowledge and skills of healthcare workers.
Training of Trainers: Guideline on Growth Management and Prevention of Malnutrition Among Children Under 5 Years
Malnutrition is one of the main health issues in children under 5 years old, be it under or over nutrition. Management of children detected with under nutrition has been addressed over the years through development of guidelines and training. This new guideline was developed to guide healthcare workers in preventing incidence of undernutrition and overnutrition among children under 5 years
Guideline was developed and piloted in Perak from January 2019 until April 2019. Subsequently training of trainers was done in two zones, attended by Family Medicine Specialist, Medical Officers and Nurses (Table 51).
The objective of the training is to:
● Improve knowledge and skills on using newborn and child growth chart (0-5 years) ● Increase knowledge about healthy lifestyle for children under 5 years including nutrition and daily activities such as sleep, exercises and screen time. ● Standardise the procedures and practices in managing children at risk for overweight or underweight ● Assists in giving appropriate health advise during consultation.
Table 51
Training of Trainers using the Guideline on Growth Management and Prevention of Malnutrition Among Children Under 5 Years
No. Zone Date States No. of participant
1. Zone 1 26-28 June Kuala Lumpur, Putrajaya, Selangor, 45 2019 Negeri Sembilan, Kelantan, (Pahang) Terengganu, Pahang
2. Zone 2 10-12 Perlis, Kedah, Pulau Pinang, Perak, 50 Melaka, Johor Sabah, Sarawak, (Kuala Lumpur) July 2019 Labuan
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Training on Guide to Assessment of 4 Year Old Children in Health Clinics
The ‘Guide to Assessment of 4 Year Old Children in Health Clinics’ was developed to assist medical officers to do assessment and identify any health issues amongst 4 year old children. The guideline is meant to complement the existing Rekod Kesihatan Bayi dan Kanak-kanak (RKBKK) (0-6 tahun) pindaan 02/2011, where every child should be examined by a medical officer at 1 month, 18 months and 4 years. Instruction letter for commencement of guideline was issued in 2016.
Training on use of this guideline was conducted together with training on prevention of malnutrition among children under 5 years. Participants who attended the training are expected to do an echo training at their state or district level for all medical officers.
Training on for health staff on Immunisation Communication
Information on immunisation is easily accessible via social media. The National Health and Morbidity Survey 2016 however reported that society still believes in healthcare workers as the source to gain information about healthcare. Thus, it is essential that all health staff especially nurses are equipped with adequate knowledge on immunisation.
Child Health Sector developed health education material to be used as a tool for nurses during consultation on immunization in 2018.
This health education material contains basic information about immunisation, vaccine preventable diseases and its complications as well as information about each vaccine in the National Immunisation Programme and its adverse reaction. There is also general information on Adverse Event Following Immunisation (AEFI).
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The trainings were conducted for nurses in four zones as shown in Table 52.
Table 52
List of Training for Healthcare Worker: Communication on Immunisation
No. Zone Date State No. of Participants
1. Zone 1 13-15 Selangor, Kuala Lumpur, 44 Negeri Sembilan, Melaka, (Kuala Lumpur) February 2019
2. Zone 2 6-8 Johor, Sabah, Sarawak, 56 Labuan (Johor) March 2019
3. Zone 3 27-29 Pahang, Kelantan, 45 Terengganu (Pahang) March 2019
4. Zone 4 10-12 Perlis, Kedah, Pulau Pinang, 42 Perak (Perak) April 2019
Seminar on Immunisation: Nurses and Communication
The seminar was conducted to update nurses on the latest issues regarding immunisation, emphasizing the important role of nurses and the importance of good communication in immunisation. The seminar was attended by nurses throughout Malaysia including both private and public sector. Due the high demand the seminar was conducted twice.
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Table 53
Immunisation Seminar: Nurses and communication
No. Date No. of Participants
1. 22 April 2019 650
2. 5 August 2019 550
Approach to Unwell Children Under 5 Years (ATUCU5) Course
ATUCU5 programme was introduced in 2016 with the objective of increasing the knowledge and skills of healthcare workers in treating children under 5 years. In collaboration with World Health Organisation, FHDD was able to further expand the programme. In 2018, the programme was improved and a manual was developed. Training of trainers was conducted in two zones in 2019 involving family medicine specialist, medical officer, nurses and medical assistance as participants.
Table 54
List of Training Approach to Unwell Children Under 5 Years (ATUCU5)
No. Zone Date States No. of participant
1. Zone 1 26-28 Kelantan, Terengganu, Pahang 36
(Pahang) June 2019
2. Zone 2 (Sarawak) 23-25 Sabah, Sarawak, Labuan 30
October 2019
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Supervision of Child's Health Programmes and Services
Supervision is one of the key elements in monitoring the quality and effectiveness of programme implementation. Findings during supervision are used for continuous improvement of the programme. Nurses carrying out the supervision must be knowledgeable and well-trained to ensure implementation of any programme is according to standards set. Supervisory visits are also a platform for supervisors to give ‘hands-on’ teaching to clinic staff.
Child Health Sector in 2016, developed a guideline on supervision of child health programme implementation to assist programme managers monitor and observe implementation of activities during supervisory visits. All supervisors are encouraged to use this guideline and give continuous training to all healthcare workers at the health clinic.
Three main activities to be supervised are newborn screening, growth and development assessment and the National Immunisation Programme. Supervision of all the activities includes 4 aspects; (i) programme achievement, (ii) implementation of activities according to standard, (iii) assessment of healthcare worker and (iv) review of documentation. By using the supervision checklist in the guideline, supervisors are able to evaluate the overall performance of all the main activities in the child health programme.
Annual target for supervision by staff from Child Health Sector is 12 health clinics. The focus for 2019 supervision visit was (i) appropriate use of growth chart, (ii) growth assessment of children 0-6 years and (iii) documentation of registered live birth into the Birth Register Book (KIB 103) and registration of child care into KKK 101. Supervisory visit for 12 facilities in 2019 involved states of Johor, Perak, Negeri Sembilan, Selangor and Melaka. Discussion on improvements required were discussed with local supervisor and all the health staff in the facility involved with child health services. The state supervisor was informed of the findings and advised on follow up supervision to ensure improvement measures were implemented.
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9 MATERNAL HEALTH CARE AND FAMILY PLANNING SERVICES
9.1 Maternal Health Care
Maternal health care essentially monitors the well-being of the mother and baby during pregnancy and continues during intrapartum and postnatal. Malaysia has made great progress in improving maternal health care with remarkable level for coverage of maternal health services. In 1990, the antenatal coverage for at least one visit was 78.1 per cent, increased to 82.2 per cent in 2010, and 97.92 per cent in 2019. From year 2014 onwards, the average antenatal visit per person remains as more than 10 visits. The coverage for tetanus toxoid immunization among antenatal mothers was 83.7 per cent in 2019. Proportion of deliveries conducted by skilled health personnel (safe deliveries) and mothers attending clinic at 1 month postnatal remained high above 95 per cent since 2010. (Table 55). Majority of deliveries (88.5 per cent) took place in government hospitals, followed by private hospitals and maternity homes (10.3 per cent) (Table 56).
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Table 55
Maternal Health Coverage in Malaysia, Selected Years 1990-2019p
1990 2000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019p
676,382 691,664 587,479 565,072 580,536 592,489 592,489 588,645 599,306 550,108 550,108 546,786
528,029 517,138 483,136 550,104 560,323 580,819 575,604 573,631 554,721 570,445 548,115 535,435
78.1% 74.8% 82.2% 97.3% 96.5% 98.0% 97.2% 96.5% 92.6% 103.7% 99.6% 97.92 %
6.6 8.5 10 9.8 10.0 9.9 10.6 10.5 10.8 10.7 10.8 11.51
414,445 449,608 432,581 451,323 466,666 461,845 478,206 476,578 466,903 479,299 448,936 457,733
81.7% 86.8% 84.6% 91.8% 92.44% 89.6% 92.8% 93.1% 89.6% 94.3% 88.3% 83.71%
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476,196 507,891 439,447 448,886 455,650 453,048 461,220 451,803 443,432 450,894 449,358 440,489
92.8% 96.6% 98.6% 98.6% 98.7% 98.8% 98.9% 99.4% 99.5% 99.6% 99.5% 99.83%
318,953 417,232 428,140 439,927 450,160 458,532 467,522 466,087 458,893 458,529 445,724 488603
67.0% 82.1% 97.4% 98% 98.8% 101% 101% 103% 103% 101% 99.2% 110.92 %
Source: Health Informatics Centre, Ministry of Health Malaysia.
Note: Data for 2017 and 2018 is preliminary.
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Table 56
Institutional and Domiciliary Deliveries in Malaysia, Selected Years 1990-2019p
1990 2000 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019p
Total Delivery 476,196 507,891 439,447 448,886 455,650 453,048 461,220 451,803 443,432 450,844 449,738 440,489
1. Government 281,473 373,254 371,368 375,619 379,080 377,394 388,287 384,298 380,883 393,952 398,216 388,100 Hospitals 88.11% and Low Risk 59.1% 73.5% 84.5% 83.7% 83.2% 83.3% 84.2% 85.0% 85.9% 87.4% 88.5% Birthing Centre
2. Private 62,675 92,280 54,400 60,035 64,553 64,694 63,063 60,831 57,104 51,889 48,594 47,976 hospitals / Maternity 13.1% 18.2% 12.4% 13.4% 14.2% 14.3% 13.7% 13.5% 12.8% 11.5% 10.3% 10.89 % homes
3. Estate 333 140 NA NA NA NA NA NA NA NA NA NA hospital 0.07% 0.03%
4. Health 13,415 14,948 7,497 6,923 5,997 5,521 5,131 3,836 3,336 3,124 4435 2,769 Fasilities (KK/KD) and 2.8% 2.9% 1.7% 1.5% 1.3% 1.2% 1.1% 0.85% 0.75% 0.69% 0.98% 0.63 % Alternative Birthing Centre
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(Health)
5. Others NA NA 210 202 249 183 171 209 160 162 157 156
0.05% 0.05% 0.05% 0.04% 0.04% 0.05% 0.04% 0.04% 0.03% 0.35%
6. Domiciliary deliveries a. Government 84,131 10,092 2,268 1,945 1,758 1,422 1,339 1,154 1,086 1,127 1040 903 midwives 0.5% 0.29% 17.7% 1.9% 0.4% 0.4% 0.3% 0.26% 0.24% 0.25% 0.23% 0.20%
b. Private 492 867 51 87 140 110 69 45 29 57 26 12 midwives 0.10% 0.2% 0.01% 0.02% 0.03% 0.02% 0.01% 0.01% 0.01% 0.01% 0.01% 0.002 %
c. Traditional 1,672 4,529 941 1,198 1,147 934 418 200 181 215 139 97 Birth Attendants 0.4% 0.9% 0.2% 0.3% 0.25% 0.2% 0.09% 0.04% 0.04% 0.05% 0.03% 0.02 % d. BBA 11,606 3,675 672 529 494 475 379 287 242 196 222 236
2.4% 0.7% 0.2% 0.1% 0.1% 0.1% 0.08% 0.06% 0.05% 0.04% 0.04% 0.05%
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e. Others 20,399 8,106 4,359 4,380 4,220 3,847 3,771 2,142 1,526 1,306 1344 1,154
4.3% 1.6% 0.9% 0.9% 0.9% 0.8% 0.82% 0.47% 0.34% 0.29% 0.29% 0.26 %
Source: Health Informatics Centre, Ministry of Health Malaysia.
P – preliminary data.
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9.2 Maternal Death Malaysia has demonstrated progress to reduce maternal mortality before year 2000. A steep decline in the maternal mortality ratio (MMR) was noted in the decade between 1960 and 1980, when it dropped from 141 to 56 per 100,000 live births. This rapid reduction continued throughout the 1980s but started to slow when it reached 1990s. During the era of MDG, the MMR of Malaysia has reduced from 44.0 per 100,000 LB in 1991 to 23.8 per 100,000 in 2015 which accounted for 45.9 per cent reduction. The reduction was slightly higher than the world performance with 44 per cent decline but lower than the Western Pacific Region, 64 per cent decline1.
However, Malaysia is now having a great challenge to further reduce the relatively low MMR. The MMR has been stagnant since year 2000, which was 24.4 per 100,000 LB in year 2000 and remained as 23.8 per 100,000 LB in 2015. The reduction is miniscule and this pattern continued until 2018 with MMR at 23.5 per 100,000 LB (Figure 71). Table 57 shows the number of maternal death and MMR by state.
Figure 71
Maternal Mortality Ratio in Malaysia, 1991-2018
Source: Department of Statistics Malaysia.
1 WHO 2015. Health in 2015:from MDGs, Millennium Development Goals to SDG, Sustainable Development Goals 123
Table 57
Maternal Mortality and Ratio (per 100,000 livebirths) in Malaysia by State, 2013-2017
2013 2014 2015 2016 2017 2018
State No. of MMR No. of MMR No. of MMR No. of MMR No. of MMR No. of MMR
death death death death death death
Perlis 0 0.0 2 44.4 3 69.5 0 0.0 1 22.5 0 0
Kedah 4 11.4 10 27.4 13 35.3 5 13.9 10 27.6 9 25.3
Pulau 3 14.0 4 17.5 6 27.0 11 50.5 9 41.9 4 19.3 Pinang
Perak 8 22.6 5 13.7 12 33.1 10 28.0 7 20.1 8 23.6
Selangor 27 26.2 19 17.4 21 19.4 31 29.6 25 24.0 20 19.6
WPKL 3 11.8 5 18.5 1 3.9 7 27.2 6 24.3 10 41.3
WP 0 0.0 2 65.3 2 69.7 0 0.0 0 0 0 0 Putrajaya
Melaka 2 14.6 5 34.3 6 41.2 4 27.8 4 27.8 4 27.8
N.Sembilan 6 34.3 7 37.5 4 21.7 1 5.5 4 22.1 6 33.0
Johor 12 20.9 16 26.5 14 23.1 16 26.9 15 24.6 17 27.8
Pahang 5 18.5 7 24.4 3 10.7 10 36.2 8 29.0 9 33.3
Terengganu 7 27.5 9 33.3 5 18.1 6 21.8 6 21.5 3 10.6
Kelantan 12 33.0 11 28.0 8 20.5 10 26.0 10 25.6 7 18.2
WP Labuan 0 0.0 0 0.0 0 0.0 1 57.1 0 0 0 0
Sabah 16 28.2 10 17.4 19 34.7 30 57.6 14 26.7 10 18.9
Sarawak 3 7.4 6 14.6 7 17.6 6 15.8 8 21.2 11 30.0
Malaysia 108 21.4 118 22.3 124 23.8 148 29.1 127 25.0 118 23.5
Source: Department of Statistics Malaysia
In the last 5 years, five common causes of maternal death were Associated Medical Conditions, Pulmonary Embolism, Postpartum Haemorrhage (PPH), Amniotic Fluid Embolism and Hypertensive 124
Disease in Pregnancy (HDP). A transition for common causes of death is observed from obstetrics causes (eg: PPH,HDP) to Associated Medical Conditions (eg: cardiac and renal disease) over the last 15 years (Figure 72). Cardiac diseases accounted for 50 per cent of Associated Medical Conditions in year 2012- 20142. However, in recent years, PPH is back and become the main cause of death. Death due to pulmonary embolism showed increasing trend and obesity was the main risk factor to develop venous thromboembolism (VTE)2. These suggest the association with non-communicable diseases in Malaysia. Another alarming cause of direct death is ectopic pregnancy, which became the 6th after Amniotic Fluid Embolism.
Figure 72:
Rolling 3-Year Average Cause Specific MMR Per 100,000 LB
For Common Causes of Maternal Death, Malaysia 2000-2018
Source: 2004-2008: Reports on the Confidential Enquiries into Maternal Deaths in Malaysia
2009 – 2018 : Family Health Development Division, MOH
2 FHDD MOH Malaysia 2019. Report on the Confidential Enquiries into Maternal Deaths Malaysia 2012-2014 125
WHO and partners has conducted a large Multi-country Survey on Maternal and Newborn Health, with a focus on the prevalence and management of severe maternal morbidities and noted that countries and world regions are transitioning in the same pathway towards elimination of maternal deaths. The phenomenon was described as ‘Obstetric Transition’ which have implications on the strategies aimed at reducing maternal mortality3. According to five stages of Obstetric Transition phenomenon, Malaysia fits in stage IV, described as MMR moderate or low (less 50 maternal deaths per 100,000 LB), low fertility, with indirect causes of maternal mortality, particularly non-communicable diseases. In order to further reduce MMR, addressing the quality of care and eliminating suboptimal care within the health systems are vital. In Malaysia, approximately 60-70 per cent of maternal deaths are preventable if timely and appropriate medical treatment instituted. The phase III delay4 i.e delay in receiving adequate care at the facility; with issues related to suboptimal care and competencies of health personnel becomes gradually critical.
To ensure an optimal care is given, activities to improve effective supervision and monitoring were in place. These include development of Guidelines on Effective Supervision of Maternal Health and Family Planning Services incorporating hands on training to senior nurses on the guidelines. Competency based training for healthcare providers also needs to be coordinated and scaled up to update their skills and knowledge.
Furthermore, increasing burden of non-communicable disease and sociodemographic shift of the population pose a challenge and add complexity to the health care of pregnant women. As the age of Malaysian women during their first marriage is getting older, their age of having first baby has also increased from 26.9 in year 2009 to 27.8 in year 2018. This explains the complicated pregnancy since advanced maternal age is one of its common risk factors.
9.3 Pre-Pregnancy Care
Strengthening of pre-pregnancy care is among imperative strategies to optimise women in reproductive age with medical condition before they embark on pregnancy. It is to ensure optimal outcome for both mother and baby.
The programme was introduced in 2003, however national roll out to MOH hospitals and clinics started in late 2011. Starting 2017, its approach and process of programme execution were reviewed based on
3 (Souza JP, Tuncalp O, Vogel JP, Bohren M, Widmer M, Oladapo OT, Say L, Gulmezoglu AM, Temmerman M. Obstetric transition: the pathway towards ending preventable maternal deaths. BJOG 2014; 121 (Suppl. 1): 1–4) 4 Thaddeus S, Maine D. Too Far to Walk: Maternal Mortality in Context in Social Science & Medicine 38(36):22- 4 · August 1994
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the findings of supervisory visits to selected clinics. The primary target group is women with chronic medical illnesses which require active interventions during inter-conception phase. One of interventions during the pre-pregnancy care is effective contraceptive whereby both safety and efficacy of the method must be considered. They have to undergo counselling sessions on family planning apart from management of medical conditions. The new approach was implemented in all MOH health clinics starting 2019. There are 5 indicators introduced:
1. Usage of contraceptives among PPC clients 2. Percentage of diabetic women in reproductive age receive PPC 3. Percentage of women with medical conditions registered in PPC (via clinical audit) 4. Percentage of women with medical conditions received adequate PPC intervention (via clinical audit) 5. Percentage of women with medical conditions optimized before embarking pregnancy (via clinical audit)
9.4 Family Planning Programme
Malaysia reported contraceptive prevalence rate (CPR) of 26.3 per cent in 1974. This has doubled to 52 per cent by 1984 and remained plateau since then. The latest CPR was 52.5 per cent in 20145 with contribution of modern method was 34.3 per cent. According to MPFS20143, the five most popular modern method used was contraceptive pill (13.2 per cent), tube ligation (6.9 per cent), male condoms (5.6 per cent), injectable (4.9 per cent) and intrauterine device (2.7 per cent). Malaysia has showed reducing trend from 24.6 per cent in 2004 to 19.6 per cent in 2014 for unmet need for family planning (both for modern and traditional method).
The Ministry of Health provides a wide range of contraceptive methods to cater for the different needs and suitability of each woman. The total number of new family planning acceptors registered in MOH clinics has increased from 120,698 (2018) to 126,086 (2019) acceptors. The number of active users has also increased from 343,811 in 2018 to 354,987 in 2019 (Table 58). The most popular contraceptive method used in year 2019 was progestogen-only injection (47.1 per cent), contraceptive pill (45.4 per cent) followed by male condoms (7.5 per cent) and intrauterine device (4.4 per cent).
Contraceptive among high risk women is another main highlight for family planning services in MOH, as part of pre-pregnancy care. It is to highlight the need for high risk women in optimising their health before embarking next pregnancy. Two indicators were monitored since 2009, i.e. practice indicator and quality indicator. However, with the introduction of new approach for pre-pregnancy care starting 2019, the definition of former indicator was reviewed and the latter was dropped. Documentation and reporting of family planning for high risk women and pre-pregnancy care were combined.
5 Laporan Penemuan Utama Kajian Penduduk dan Keluarga Malaysia KeLima 2014, LPPKN 127
Table 58
Number of New Acceptors and Active Users by State, 2015-2019p
New Acceptors Active Users State 2015 2016 2017 2018 2019p 2015 2016 2017 2018 2019p
Perlis 1,169 1,073 1,027 1,091 948 4,298 4,588 5,140 6,031 4,886
Kedah 10,822 10,588 10,062 9,919 10,253 33,532 35,042 33,948 35,084 38,688
P.Pinang 7,192 7,292 7,632 7,610 8,218 9,071 12,434 10,497 11,363 11,843
Perak 8,740 8,250 7,956 8,294 8,827 18,568 22,072 25,032 24,430 26,700
WP KL 4,556 4,666 5,649 6,934 6,515 6,812 7,415 7,436 8,118 8,098
WP Putrajaya 475 443 629 6,95 874 1,304 1,262 1,043 914 1,377
Selangor 17,346 18,168 19,918 21,943 24,482 26,805 28,425 22,184 27,381 32,264
N.Sembilan 4,817 4,269 3,737 4,083 4,269 11,846 13,467 21,380 11,589 11,483
Melaka 3,549 3,411 3,274 3,699 4,006 8,950 8,545 7,706 8,205 10,246
Johor 12,491 11,527 11,986 12,524 13,763 31,438 30,000 29,922 25,698 34,384
Pahang 8,103 7,362 7,099 6,901 7,026 30,254 35,893 33,877 31,839 31,072
Terengganu 7,038 6,545 6,664 6,681 6,744 20,971 21,471 21,245 25,457 18,886
Kelantan 7,632 7,482 6,775 6,879 6,560 22,214 25,549 25,726 29,415 27,528
Labuan 496 437 470 476 493 1,674 1,660 1,489 1,874 1,857
Sabah 13,148 12,831 12,452 12,275 12,752 51,864 48,679 47,780 48,902 51,007
Sarawak 13,090 11,555 10,430 10,694 10,356 52,224 39,841 43,505 47,511 44,668
Malaysia 120,664 115,899 115,760 120,698 126,086 331,825 336,343 337,913 343,811 354,987
Source: Health Informatics Centre, Ministry of Health Malaysia.
P – preliminary data.
The fertility rate in Malaysia continues to decline, in year 2018 it was at 1.8 babies per woman, below the replacement level of 2.1 babies. Concurrent with the decline in birth rates, the average age of the mother at first birth has risen from 26.9 in year 2009 to 27.8 in year 2018. In general, this indicates a shorter reproductive period in women in Malaysia. Therefore, important message on family planning to the women and their spouses is spacing the birth, not limiting birth.
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Increasing availability of various methods of contraceptives especially long-acting reversible methods (i.e implants, intrauterine contraceptive device (IUCD) and injectables) may improve the proportion of women who have their family planning needs satisfied using modern methods. This is particularly an important strategy for women in high-risk groups as these methods require administration less than once per cycle or month. However, availability of implants in health clinics is still limited since the method is relatively expansive.
9.5 Highlights
In 2019, three main activities were training of senior nurses on effective supervision, implementation of reviewed approach of pre pregnancy care and revision of perinatal care manual and other manuals.
Effective supervision and monitoring is one of critical measures to ensuring services are delivered as per standard guidelines. Training workshops were carried out in 2 zones i.e Northern Zon ((Perlis/Kedah/Pulau Pinang/Perak) in August 2019 and Klang Valley Zone (Selangor/ Wilayah Persekutuan Kuala Lumpur & Putrajaya)in September 2019. The trainees were guided to conduct supervision according to Buku Panduan Penyeliaan Program Perkhidmatan Kesihatan ibu dan Perancang Keluarga di Klinik Kesihatan.
The guidelines on reviewed approach of pre-pregnancy care at primary health care level has finalized, and the principle was to integrate PPC into the management of common medical conditions among women in reproductive age. It also combines the documentation of family planning for high risk women and pre-pregnancy care. Briefing session was conducted at national level in February 2019 for nationwide implementation starting June 2019. There are 5 indicators introduced in the new approach, which encompass family planning for high risk women, registration of diabetic women in PPC and the quality component of PPC. The quality component is assessed retrospectively among pregnant women with medical conditions via clinical audit and expected to kick-off in 2020.
Sessions of meeting and discussion continued to revise and update the three key materials in maternal health services i.e Perinatal Care Manual 3rd Edition 2013 , Garis Panduan Senarai Semak Bagi Penjagaan Kesihatan Ibu dan Bayi Mengikut Sistem Kod Warna Edisi 4 2013 and Buku Rekod Kesihatan Ibu (pink card). Except for Perinatal Care manual, the documents are probable to complete by early 2020.
In tandem with review of Perinatal Care manual and other main documents, FHDD has taken the opportunity to re-visit the policy of postnatal home visits (number and schedule) and recommendation by Institute of Medicine 2009 on gestational weight gain. FHDD also worked with Nutrition Division to study the feasibility of the new criteria in health clinics before its implementation, possibly in 2020.
FHDD has also published two references in year 2019 ; Report on Confidential Enquiries into Maternal Deaths in Malaysia 2012-2014 and Buku Panduan Latihan Prosedur Pemasangan dan Pengeluaran Alat Dalam Rahim untuk Pegawai Perubatan di Fasiliti Kesihatan Primer. A 2-days training session was
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organised on 14th and 15th of November 2019 to share on good practices for better maternal death reports. Amongst participants were state family health officers, family medicine specialist and senior nurses.
There were 12 health clinics and 12 klinik desa visited in year 2019. The monitoring activities by immediate supervisors have generally improved, however the component of supervisory visits need to take emphasis on clinical management of patients, particularly high risk mothers.
10 SCHOOL HEALTH SERVICES The school health program was established in 1967, with the objective of ensuring the health of Malaysian students at an optimal level. Students received periodic regular school health visits, which started during pre-school up to Form 4. The health services consist of health education, health screening and apraisal, immunization, treatment of minor ailments and early referral.
10.1 School Health Services Coverage
Figure 73 shows the trend of school service coverage by the paramedics. Overall, the services coverage based on enrollment for Year 1, Year 6 and Form 3 students are over 98 per cent over the last 10 years. For pre-school children, the service exceeded 98 per cent since 2013 and maintained there after.
Figure 73
School Health Service Coverage Trends, 2010-2019
Source: Health Informatics Center, MOH (2015-2019)
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10.2 Morbidity Detected Among School Children
10.2.1 Nutrition status of school students
Figure 74 shows the overweight trend of Year 1, Year 6 and Form 3 students between 2009 to 2019. The trend shows that there is an increase in the percentage of overweight students for all Year 1, Year 6 and Form 3 cohorts. Students with overweight problems ranged from 5.29 per cent to 6.46 per cent. This percentage increase since 2012. For Year 6 students, there has been an increase in the percentage of overweight students over the last 10 years ranging between 8.66 per cent to 11.72 per cent. For Form 3 students, the percentage increase in overweight between 7.05 per cent to 9.45 per cent for the same period.
A comparison between the three Year 1, Year 6 and Form 3 cohorts shows that the Year 6 cohort has a higher percentage of overweight students than Year 1 students. This may be due to the pattern of food intake in primary school. The Form 3 student cohort has a lower percentage of overweight students than the Year 6 cohort. This may be due to the relative increase in height related to growth during adolescence.
Figure 74
Overweight Trend Among School Children, 2009-2019
Source: Health Informatics Center, MOH 2009-2019
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Figure 75 shows the obesity trend of Year 1, Year 6 and Form 3 students between the period 2009 to 2019. The trend shows that there is a slight increase in obesity percentage for all Year 1, Year 6 and Form 3 cohorts. For Year 1 students, the percentage of students with obesity is between 5.37 per cent to 6.32 per cent. There is a significant increase in the percentage of year 6 students with obesity since 2011 which is between 8.07 per cent to 10.24 per cent. For Form 3 students, there is an increase in the percentage of students with obesity by 6.18 per cent to 7.13 per cent. A comparison between the three Year 1, Year 6 and Form 3 cohorts shows that the Year 6 cohort has a higher percentage of students with obesity than Year 1 students. This may be due to the pattern of food intake in primary school. The Form 3 student cohort has a lower percentage of students with obesity than the Year 6 cohort. This is likely due to the increased growth rate during adolescence, ie there is an increase in relative height during adolescence.
Figure 75
Obesity Trend Among School Children, 2009-2019
Source: Health Informatics Center, MOH 2009-2019
The 5 years trend of overweight among Year 1 school students in Malaysia shows that the Federal Territory of Labuan has the highest percentage of Year 1 school students with overweight. Several states have shown an increase in overweight trends among Year 1 students, are Perlis, Penang, Perak, Melaka, Pahang, Terengganu, Sabah, Sarawak and the Federal Territory of Labuan.
Figure 76 shows the 5-year trend of overweight among Year 6 school children in Malaysia by state. Overall, Perlis, Federal Territory of Kuala Lumpur and Federal Territory of Labuan show the highest percentage of overweight school children among Year 6 students.
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Figure 76
Overweight Trend Among Year 6 School Children by State, 2015-2019
Source: Health Informatics Center, MOH 2019 Figure 77 shows the 5-year trend of overweight among Form 3 school students in Malaysia by state. Overall, Perlis, the Federal Territory of Kuala Lumpur and the Federal Territory of Labuan show the highest percentage of overweight school children among Form 3 students.
Figure 77
Overweight Trend Among Form 3 School Students by State, 2015-2019
Source: Health Informatics Center, MOH 2015-2019
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Figure 78 shows the 5-year trend of obesity among Year 1 students in Malaysia by state. Overall, Perlis, the Federal Territory of Kuala Lumpur, Sarawak and the Federal Territory of Labuan show the highest percentage of obesity among Year 1 students.
Figure 78
Obesity Trend Among Year 1 School Students by State
Source: Health Informatics Center, MOH 2019 Figure 79 shows the 5-year trend of obesity among Year 6 students in Malaysia by state. Overall, Perlis, the Federal Territory of Kuala Lumpur and the Federal Territory of Labuan show the highest percentage of Year 6 students with obesity among.
Figure 80 shows the 5-year trend of obesity among Form 3 school students in Malaysia by state. Overall, Perlis and the Federal Territory of Labuan show the highest percentage of Form 3 students with obesity.
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Figure 79
Obesity Trend Among Year 6 School Children by State
Source: Health Informatics Center, MOH 2019
Figure 80
Obesity Trend Among Form 3 School Students by State
Sours ource: Health Informatics Center, MOH 2019
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10.2.2 Learning Disabilies
Figure 81 shows the trend of students who have learning disabilities for the period 2013 to 2019. A total of 17,344 Year 3 students was diagnosed to have learning disability since the Literacy and Numeracy screening program (LINUS) was introduced in2013. Between 2013 to 2019, the incident of Year 3 students with all types of learning disability increases between 31 students to 72 students for every 10,000 students examined. Of those, the highest incidence rate of learning disabilities is intellectual disabilities with incidence ranges between 18 to 36 students for every 10,000 Year 3 pupils, followed by specific learning disabilities.
In 2019, there is a decrease in the incidence of problems in learning disability as the LINUS program was doiscontinued by the Ministry of Education Malaysia starting 2019.
Figure 81
Trends of Students Who Have Learning Disabilities, 2013-2019
Source: Family Health Development Division 2013-2019
10.3 School Health Service Immunization Coverage
10.3.1 HPV immunization
The School based HPV immunization for Form 1 female students was introduced in 2010 with the aim of preventing cervical cancer among HPV immunization recipients. Figure 82 shows the trend of parental
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consent, remained above 98 per cent since 2012. The coverage of Dose 1 and students who completed immunization among those with written permission remained above 99 per cent since 2012. However, the percentage of completed HPV vaccination in the population of 13 years old girls is between 83.22 per cent and 93 per cent for the period 2010 to 2019.
In general, all states showed more than 95 per cent coverage since 2010. There was a decrease in in coverage from 2016 to 2018 for the states of Melaka and Sarawak before picking up in 2019. The Federal Territory of Putrajaya showed a decrease reduced in coverage for 2018 and 2019 compared to 2017 .
Figure 82
HPV Immunization Achievement of Form 1 Female Students, 2010-2019
Source: Family Health Development Division 2013-2019
10.3.2 Other School Immunizations
With reference to Figure 83, booster DT and MR immunization for Year 1 and Booster ATT immunizations for Form 3 students coveraga exceeded 98 per cent since 2012. Booster DT immunization achievements exceeding 95 per cent for the period 2010 to 2019 in most states. Perlis shows a slight decrease in vaccination coverage since 2016. The Federal Territory of Kuala Lumpur showed increased in school based vaccination coverage between 2010 to 2015 before declining in trend in 2017. The Federal Territory of Putrajaya also showed a decrease vaccination coverage between 2014 to 2018 before increasing in 2019. Similarly, Melaka showed a consistent decline in coverage starting from 2016, Terengganu showed decrease in vaccination coverage after 2010 while Sarawak showed a slight
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decrease the vaccination coverage since 2014. Sarawak showed a low average in vaccination coverage compared to other states. Decreased DT immunization coverage in some states may be due to several factors such as vaccine hesitancy.
Figure 12
Additional DT And MR Immunizations for Year 1 Students
and Additional ATT Immunizations for Form 3 Students, 2010-2019.
Source: Health Informatics Center, MOH 2010-2019 Overall, MR immunization coverage exceeding 95 per cent from 2010 to 2019 in most states. However, Sarawak showed an average lower coverage compared to other states. There was an increase vaccination coverage from 2010 to 2015 for the Federal Territories of Kuala Lumpur and Sarawak,
Between 2010 to 2019, the achievement of ATT immunization coverge in most states exceed 95 percent with exception of Sarawak, which has low ATT vaccination coverage.
10.4 School Health Sector Meetings in 2019
10.4.1 Electronic School Health Record Roadshow (eRKM)
A total of 15 series of Roadshows at the state level were implemented in collaboration with the School Management Division, Ministry of Education. The objective of roadshow was to provide awareness and training to the members of School Health Team, District Education Officers and school represenatatives on eRKM operations. The roadshow began on the 7th January and end in March 2020. A total of 2 series of coordination meetings with MOE and State Education Department were held in 2019 to identify and overcome the implementation problems raised by the School Health Team.
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10.4.2 Expansion of School Health Services to Private Religious Schools
The planning of introducing the School Health Services into religious schools began in January 2019 when JAKIM invites School Helath Sector to present the proposal on the 19th February 20219 during the 108th National Islamic Council/ Head of Department consultation. The members of the committee have unanimously agreed for the School Health Services to be implemented in religious schools registered under the States Religious Department.
The school health services for students in religious schools was propose because of high demand for school health services from religious schools; the importance of ensuring immunization services being provided to students in both the government and private religious schools and religious schools are one of the largest components of educational institutions apart from mainstream schools.
Following the JAKIM’s decision, a follow-up discussion by the JAKIM Policy Development Division took place on 15 March 2019. The Deputy Director of JAKIM Islamic Development Policy Division agreed that JAKIM would act as a main stakeholder and coordinator at the central level in collaboration with MOH. Joint Health Committees was established at the central and state levels to coordinate and monitor the implementation of services.
A briefing on the expansion of School Health Services to religious schools was also given to all representatives of the State Islamic Religious Department on 24 June 2019 at the Meeting of the Religious Education Coordination Committee and KAFA (JKPP) No. 1/2019 chaired by the Director General of JAKIM. Following the agreement from the meeting, the first School Health Services Joint Committee was formally established on 28 August 2019. Committee members at this central level consisted of representatives from JAKIM, MOH, MOE and all State Islamic Religious Departments
10.4.3 Use of Rapid Assessment Visual Acuity Chart (RAVAC) as a school screening method for school students
A meeting with Ophthalmologists and Optometrist officials was held on 19 December 2020 for the use of the RAVAC chart to replace the Snellen Chart. RAVAC is the result of an innovation produced by Mr. Nazirin bin Arsad, an Optometrist Officer who works at the Sarawak General Hospital.
The decision to introduce RAVAC to replace the Snellen Chart was based on the a pilot project study findings. The pilot project in 8 states found that RAVAC have good reliability, short time to implement the screening, the RAVAC guideline was easily understood by teachers and there is no difference in the findings by school teams and teachers who did not receive training on RAVAC.
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Rapid Assessment Visual Acuity Chart (RAVAC)
10.5 School Health Service Monitoring Visit
A total of 7 School Health Service monitoring visits were carried out in 2019 involving 6 districts, namely the Federal Territory of Labuan, Tawau District, Pitas, Kota Marudu and Kudat in Sabah and Bintulu and Miri districts in Sarawak.
Conclusion
The achievement of School Health Services in 2019 shows increased cooperation with various agencies such as JAKIM, State Islamic Religious Department and introduced new innovation in the delivery of better quality services to the target group.
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Thalassaemia Control And Prevention Program
10.6 School Based Thalassemia Screening
Thalassemia Screening Form 4 students were introduced in 2016 which aims at reducing the birth rate of babies with Thalassemia by 95 per cent by 2038.
10.6.1 Screening Coverage
A total of 380,377 Form 4 students were enrolled in 2019. Of those, 321,961 (84.6 per cent) were offered Thalassaemia screening (Figure 15), 291,912 (90.7 per cent) had parental consent to undergo screening tests and finally 281,125 students (96.3 per cent) with parental consent underwent screening tests.
Figure 84
Number of Form 4 Students Offered Screening Services, Student with Parental Consent and Underwent Thalassemia Screening for 2019
Source: Family Health Development Division 2019
Figure 85 shows increase of 2.72 per cent of parents consented and 1.28 per cent increase in students who undergo screening in 2019 compared to 2018. The increase in parental consent and number of students participated in screening could be reflected by increase awareness on the importance of Thalassaemia screening among parents and students.
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Figure 85
Trends in Total Enrollment, Screening Coverage, Parental Consent and Thalassemia Screening for Form 4 Students, 2016-2019
Source: Family Health Development Division 2016-2019
Figure 86 and Figure 87 Trends of Students with Parental Consent for Thalassemia Screening by Gender, 2016-2019
Source: Family Health Development Division 2010-2016
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There has been an increase in the percentage of male and female students who have permission from parents to undergo screening since 2016. Although the trend parental consent has increased for both male and female students, the percentage of male students who agree to undergo screening test is still low compared to female students. The percentage of female students with parental consent was 94.5 and of those 90.9 per cent underwent screening. Amongst the male Form 4 students, only 87.1 per cent of students had parental consent and of that number 83.4 per cent underwent screening tests. The same trend has been observed since 2016.
Figure 88
Number and Percentage of Form 4 Students Undergoing Thalassemia Screening by Ethnic Group and Gender for 2019
Source: Family Health Development Division 2010-2016
Figure 88 shows the number and percentage of Form 4 screening by ethnic group. The highest percentage in screening was among the Malay etnic with 172,218 (61.3 per cent), followed by the Chinese, Bumiputra Sabah and Bumiputra Sarawak. The percentage of female students undergoing screening was higher than male students in all ethnic groups.
Table 59 shows the achievement of Form 4 Thalassemia screening by state in 2019. The states of Melaka, Terengganu, Penang and Johor have parental consent less than 90 per cent. The highest percentage of screening was in the Federal Territory of Labuan (99.5 per cent), Sabah (98.5 per cent) and Negeri Sembilan (98.1 per cent). The states with the lowest screening achievement were the Federal
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Territories of Kuala Lumpur and Putrajaya (92.6 per cent). The State of Selangor conducts the highest number of screening (55,445) followed by Sarawak (30,663), Sabah (28,828), Perak (23,182) and Kedah (22,184).
Table 59
Enrolment, Parental Consent and Form 4 Thalassaemia Screening by State 2019
State Form 4 Students with Parental Students Screened Enrolment Consent
No. Per cent No. Per cent
Perlis 3,948 3,684 93.31 3,503 95.09
Kedah 24,715 23,284 94.21 22,184 95.28
Pulau Pinang 19,121 16,955 88.67 15,907 93.82
Perak 26,051 24,208 92.93 23,182 95.76
Selangor 65,450 57,215 87.42 55,445 96.91
WP Kuala Lumpur & 16,034 14,161 88.32 13,118 92.63 Putrajaya
Negeri Sembilan 14,152 13,518 95.52 13,256 98.06
Melaka 12,988 10,918 84.06 10,283 94.18
Johor 20,430 18,229 89.23 17,780 97.54
Pahang 16,466 15,298 92.91 14,904 97.42
Terengganu 16,169 14,055 86.93 13,450 95.70
Kelantan 19,991 18,328 91.68 17,639 96.24
Sabah 32,164 29,281 91.04 28,828 98.45
Sarawak 33,211 31,790 95.72 30,663 96.45
WP Labuan 1,071 988 92.25 983 99.49
Malaysia 321,961 291,912 90.67 281,125 96.30
Source: Family Health Development Division 2019
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10.6.2 Preliminary Screening Test Results
The preliminary result of the screening test is based on the ‘Full Blood Count’ (FBC) test. FBC test results is used as preliminary screening result and is classified into 4 groups, namely Non- Beta Thalassemia carrier, Suspected of Thalassaemia carrier, students suspected of iron deficiency (IDA) and students suffering from other types of anemia.
Figure 89 shows the trend of FBC test results for the period 2016 to 2019. In general, students identified as non Beta Thalassemia carrier remains at 62 percent since 2017. A total of 69,903 or 24.9 percent of students were suspected as Beta Thalassaemia carrier and proceed to Hb analysis tests in 2019. Another 12.21 percent of students were suspected of having Iron Deficiency Anaemia and the remaining 0.56 percent of students suffer from anemia of various causes.
Figure 89
Trend of Preliminary Thalassemia Screening Result Based on FBC Test, 2016-2019
Source: Family Health Development Division 2019
Table 60 shows the preliminary results of Thalassemia screening by state in 2019. Perlis (32.3 per cent) had highest percentage of form 4 students suspected of Beta Thalassaemia carriers, followed by Kedah (31.0 per cent), Federal Territory of Labuan (29.4 per cent), Terengganu (27.9 per cent) and Sabah (27.8 per cent). Sarawak (16.0 per cent) hadh the lowest percentage of Form 4 students suspected of of Beta Thalassaemia carriers. Perlis, Kedah, Penang, Selangor, Negeri Sembilan, Sabah and the Federal Territory of Labuan have more than 13 percent students suspected of Iron Deficiency Anaemia while Sarawak has the lowest number of students with Iron Deficiency Anemia at 7.6 percent
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Figure 90 shows the preliminary Form 4 Thalassemia Screening by ethnic group for the year 2019. Among those suspected of Thalassemia carriers, 24.9 per cent are 16.9 per cent are of Malays ethnicity followed by Bumiputera Sabah (2.8 per cent), Chinese (2.2 per cent), Indian (1.6 per cent) and Bumiputera Sarawak (1.3 per cent).
Among the students who were suspected as Thalassemia Beta carriers, the Malay ethnic group predominates. Similarly Malay etnic have higher percentage of IDA, followed by Bumiputera Sabah (11.17 per cent), Chinese (8.71 per cent), Indian (6.46 per cent), Bumiputera Sarawak (5.93 per cent) and other ethnic groups (0.72 per cent). The percentage of female students suspected of carrying Thalassemia Beta is higher than male students of all ethnic groups.
Table 60
Preliminary Form 4 Thalassaemia Screening Results by State 2019
States Total Not Beta Suspected Beta Suspected IDA Other Form 4 Thalassaemia Thalassaemia anaemia Students carrier Carrier Screened No % No % No % No %
Perlis 3503 1736 49.6 1130 32.3 556 15.9 81 2.3
Kedah 22184 12008 54.1 6879 31.0 3114 14.0 183 0.8
Pulau Pinang 15907 9526 59.9 4215 26.5 1995 12.5 171 1.1
Perak 23182 14673 63.3 5669 24.5 2674 11.5 166 0.7
Selangor 55445 33664 60.7 14256 25.7 7316 13.2 209 0.4
Wilayah 13118 8228 62.7 3242 24.7 1539 11.7 109 0.8 Persekutuan Kuala Lumpur and Putrajaya
Negeri Sembilan 13256 8710 65.7 2741 20.7 1776 13.4 29 0.2
Melaka 10283 6477 63.0 2537 24.7 1195 11.6 74 0.7
Johor 17780 11649 65.5 4018 22.6 2074 11.7 39 0.2
Pahang 14904 9495 63.7 3635 24.4 1693 11.4 81 0.5
Terengganu 13450 8217 61.1 3749 27.9 1443 10.7 41 0.3
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States Total Not Beta Suspected Beta Suspected IDA Other Form 4 Thalassaemia Thalassaemia anaemia Students carrier Carrier Screened No % No % No % No %
Kelantan 17639 10765 61.0 4624 26.2 2051 11.6 199 1.1
Sabah 28828 16283 56.5 8003 27.8 4474 15.5 68 0.2
Sarawak 30663 23371 76.2 4916 16.0 2281 7.4 95 0.3
Wilayah 983 516 52.5 289 29.4 151 15.4 27 2.7 Persekutuan Labuan
Malaysia 281125 175318 62.4 69903 24.9 34332 12.2 1572 0.6
Source: Family Health Development Division 2019
Figure 90
Number of Students Suspected of Thalassemia Carrier by Ethnic Group for 2019
Source: Family Health Development Division 2019
10.6.3 Detection of Iron Deficiency Anaemia
Students are classified as anemia when the hemoglobin level is less than 13g / dL for male students or less than 12g / dL for female students. Anemia is categorized as iron deficiency anemia (IDA) when the MCH level ≤27 pg. and anemia for various other reasons when MCH> 27pg.
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Figure 91
Trends of Suspected IDA and Other Types of Anemia Among Form 4 Students Screened, 2016-2019
Source: Family Health Development Division 2010-2016
In 2019, a total of 34,332 (12.2 per cent) students who were suspected of having anemia due to iron deficiency (IDA). The number of students suspected of having IDA increased by 14,003 people (1.89 per cent) from 2016 to 2019. The percentage of students with other types of anemia remained between 0.5 to 0.6 for the same period (Figure 91).
Penang, Negeri Sembilan, Selangor, Kedah, Sabah, Federal Territory of Labuan, and Perlis have detected more than 13 percent Form 4 students with anemia (Figure 92). However, the highest number of suspected IDA were detected in Selangor (7,316), followed by Sabah (4,474) and Kedah (3,114).
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Figure 92
Percentage of Form 4 Suspected of IDA and Other Types of Anemia by State in 2019
Source: Family Health Development Division 2010-2016
Figure 23
Percentage of Form 4 Students Suspected of Having IDA by Ethnicity and Gender for 2019
Source: Family Health Development Division 2019 149
The highest percentage of IDA was among the Malay followed by Bumiputera Sabah (12.55 per cent) and the Indian (10.18 per cent) (Figure 93). The percentage of Female suspected of having higher IDA is higher than male students across all ethnic groups. The percentage of female Form 4 students suspected with IDA was higher than boys at 74.8 percent (29,996).
10.6.4 Confirmation using Hb Analysis Test
The 2016 School Based Form 4 Thalassemia Screening Guidelines has adopted the practice of reflect testing whereby the same sample of blood is used for both FBC test and Hb Analysis test.
Figure 94
Percentage and Number of Students Requiring Molecular Testing
Based on Hb Analysis Test Results, 2016-2019
Source: Family Health Development Division 2019
In 2019, a total of 79,535 (28.3 per cent) samples were sent for the Hb Analysis test to confirm Thalassemia carriers status. Of these, 22,493 (28.7 per cent) students had to undergo further DNA Analysis tests
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Figure 95
Results of Hb Analysis Test, 2016-2019
Source: Family Health Development Division 2019
Figure 95 shows the Results of the Hb Analysis Test for the period 2016 to 2019. In 2019, a total of 41,550 students (52.24 per cent) were confirmed as non-carriers of Thalassemia Beta through Hb analysis test. A total of 8,671 people (10.9 per cent) Form 4 students were confirmed as Carriers of HbE and 3,897 (4.9 per cent) were confirmed as Carriers of Thalassemia through this test.
The results of the 2019 HB Analysis analysis by state are shown in Table 61. All states detected a higher number of Hb E carriers than the number of Beta Thalassemia carriers. The highest number of HbE Carriers is in the state of Kelantan(1,627) followed by Selangor (1,219), Pahang (886) and Kedah (863). The highest number of Thalassemia Beta carriers were in Sabah and the Federal Territory of Labuan with 1,266 carriers followed by Selangor, Kedah and Perak with 447, 330 and 303 carriers respectively.
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Table 61
Confirm Thalassaemia Carriers Through Hb Analysis by State 2019
State Not Beta Beta HbE Carrier Iron Deficiency Thalassaemia Thalassaemia Anaemia Carrier Carrier
Perlis 17 2 3 1 Kedah 4,064 330 863 39 Pulau Pinang 2,548 139 454 67 Perak 3,399 303 660 91 Selangor 7,408 447 1,219 169 Negeri Sembilan 1,539 155 434 412 Melaka 1,753 104 307 55 Johor 2,289 201 514 650 Pahang 2,129 228 886 33 Terengganu 2,120 136 852 16 Kelantan 4,506 247 1,627 73 Sabah & WP Labuan 5,118 1,266 534 54 Sarawak 3,751 248 145 55 WP Kuala Lumpur & 909 91 173 16 Putrajaya MALAYSIA 41,550 3,897 8,671 1,731
Source: Family Health Development Division 2019
10.6.5 DNA Analysis Test Results
Carriers of Alpha Thalassemia and hemoglobinopathies can only be confirmed through DNA Analysis tests. In 2019, Alpha DNA Analysis test for Form 4 Thalassemia screening were conducted in 3 reference laboratories, namely, Kuala Lumpur Hospital Laboratory, Medical Research Institute Laboratory and Sultanah Bahiyah Hospital Laboratory, Alor Setar. The tests conducted at Sultanah Bahiyah Hospital were limited to samples from the states of Perlis and Kedah.
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Figure 96
Trend Percentage of Hb Analysis Test Results Requiring Molecular Testing, 2016-2019
Source: Family Health Development Division 2016-2019
Figure 96 shows the percentage of DNA Analysis Tests performed according to the types of Thalassemia and hemoglobinopathy. The trend shows a decrease in the percentage of confirmation tests for Alpha Thalassemia patients from 26.87 per cent in 2016 to 24.24 per cent in 2017 after the DNA code Analysis D16 was introduced. In 2019, a total of 19,564 (24.06 per cent) Form 4 students underwent DNA Analysis tests to confirm the status of Carrier Thalassemia Anemia. This number increased by 1,433 people (0.6 per cent) compared to 2018.
Table 62 shows the number of molecular tests for confirmation of Thalassemia by state. As of December 2019, a total of 22,493 DNA Analysis tests have been conducted, of which 19,564 were for Alpha Thalassemia. This number does not indicate the actual number of tests conducted in 2019 as there are still cases under investigations.
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Table 62
Form 4 Students Who Need to be Further Tested with Molecular Testing by Type of Thalassemia by State for 2019
State Thalassaemi Alpha Beta HbE Haemo- Total a Patients Thalassaemia Thalassaemia Carriers globinopathy Carriers Carriers Carriers Perlis - 20 - - 2 22 Kedah 10 2,386 73 279 86 2834 Pulau 2 1,113 44 34 42 1235 Pinang Perak 5 1,684 56 69 57 1871 Selangor 8 2,940 128 137 284 3497 Negeri 36 715 38 24 38 851 Sembilan Melaka 2 665 28 9 17 721 Johor 2 951 369 18 38 1378 Pahang 3 1,243 34 53 36 1369 Terengganu 5 860 38 62 71 1036
Kelantan 10 1,889 73 220 100 2292 Sabah & WP 10 2,979 46 52 18 3105 Labuan Sarawak 8 1,592 30 12 28 1670 WP Kuala 32 527 32 5 16 612 Lumpur & Putrajaya
MALAYSIA 133 19,564 989 974 833 22,493 Source: Family Health Development Division 2019
10.7 Thalassemia Carriers among the Form 4 Students in 2018
In 2018, a total of 279,588 Form 4 students underwent Thalassemia screening. Figure 97 shows the status of Thalassemia screening in 2018. A total of 242,188 students (86.6 per cent) have completed the screening and confirmation test in 2018 while the remaining 37,370 (13.4 per cent) failed to complete screening and confirmation test. Of those, 226,636 students (81.07 per cent) were confirmed as not Beta
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Thalassemia, 15,532 (5.6 per cent) were confirmed as carriers of Thalassemia and 20 people (0.01 per cent) were confirmed as Thalassemia patients.
Figure 97
Thalassemia Screening Status of Form 4 Students for 2018
Source: Family Health Development Division 2018
Figure 98 shows the breakdown of Thalassemia carriers of Form 4 students for the Year 2018. HbE carriers (7,378, 48 per cent) were highest in 2018, followed by Alpha carriers (4728, 30 per cent), Thalassemia Beta carriers (3321, 21 per cent) and carriers Haemoglobinopathy (105, 1 per cent).
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Figure 98
Breakdown of Thalassemia Carriers of Form 4 Pupils for 2018
Source: Family Health Development Division 2018
Table 63 shows the number of confirmed Thalassemia carriers among Form 4 students in 2018 by state. Almost all states except Sabah and the Federal Territory of Labuan show a higher number of carriers of Thalassemia Hb E compared to Carriers of Thalassemia Beta. States in the East Coast such as Terengganu, Pahang and Kelantan have more carriers of Thalassemia HbE compared to other states. Carriers of Thalassemia Alpha are more common in the states of Kedah, Kelantan, Sabah and Selangor.
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Table 63
Number of Confirmed Thalassaemia Carrier Among Form 4 Students by State 2018
State Alpha Beta HBE Carrier Other Types of Total Thalassaemia Thalassaemia Haemo- Carrier Carrier Carrier globinopathies Perlis 0 35 113 0 148 Kedah 925 305 916 36 2182 Pulau Pinang 347 161 401 9 918 Perak 282 134 288 4 708 Selangor 448 307 1044 6 1805 WP Kuala 294 139 312 2 747 Lumpur & Putrajaya Negeri Sembilan 182 135 399 5 721 Melaka 130 68 283 3 484 Johor 315 250 646 5 1216 Pahang 396 193 687 11 1287 Terengganu 193 130 722 9 1054 Kelantan 508 174 1088 11 1781 Sabah 456 1046 350 4 1856 Sarawak 244 209 116 0 569 WP Labuan 8 35 13 0 56 Malaysia 4728 3321 7378 105 15532 Source: Bahagian Pembangunan Kesihatan Keluarga 2018
10.8 Monitoring Visits
In 2019, 2 monitoring visits to Tawau in Sabah and the Federal Territory of Labuan were made. It was observed that the implementation of the Form 4 Thalassemia screening improved when compared to the previous year. Similarly Health personnel awareness on the importance of Form 4 Thalassemia screening and knowledge in the delivery of Thalassemia counseling has increased.
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10.9 Thalassemia Control and Prevention Program Strategic Plan
The meeting to developed 2020-2025 Thalassemia Control and Prevention Program Strategic Plan was held on 25-27 June 2020 at Hotel De Palma, Ampang. The strategic plan framework for control and prevention activities iderntified the Medical Development Division to be responsible for the Management of Thalassemia Patients while the Family Health Development Division is responsible for the prevention of Thalassemia.
10.10 Thalassemia Control and Prevention Program Steering Committee Meeting The Thalassemia Control and Prevention Program Steering Committee Meeting focusses on Ministry of Health future direction for the Thalassemia Control and Prevention Program. This meeting was alternately chaired by the Director of the Family Health Development Division and the Director of the Medical Development Division. The Director of the Health Development Division chaired the first meeting on 5 April 2019.
To achieve Thalassemia Control and Prevention Program goal, the Steering Committee terms of reference provides direction for MoH to plan, implement, monitor and evaluate programs performance, planning for resource requirements, encourage research in various field including the economic and impact studies through collaboration with relevant agencies.
Members of the Steering Committee for Thalassemia Control and Prevention Committee are representatives from Divisions and Institution within the MOH. Amongst the organisations are the National Blood Center, National Research Institutes, and Public Health Laboratories. Head of Pediatrics, Medicine, Pathology, Obstetrics and Gynecology, Genetics, Radiology, Family Medicine, Psychology and Counseling and Professional Association of Thalassemia are members to this committee as well.
Conclusion
The establishment of the Thalassemia Control and Prevention Program Steering Committee, development of National Strategic Plan and improvement in the quality of Thalassaemia Carrier data analysis were efforts taken in 2019 towards achieving the reducing the number of new Thalassemia births by 2038.
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11 ADOLESCENT HEALTH SERVICES
Adolescent Health Programme was established in 1996 as one of the expanded scope of Family Health Development Division (FHDD). This program aims to develop and strengthen health services for the adolescent population.
The National Adolescent Health Policy was developed in 2001, followed by the National Adolescent Health Plan of Action 2006-2020 and 2015-2020.
11.1 Adolescent Health Services Coverage
In 2019, the Malaysian adolescent (10-19 year old) population is 5,385,700 or 17 per cent of the total Malaysian population. A total of 350,567* (6.5 per cent) adolescents were screened using health screening status form (BSSK) (Figure 99). Among those screened 38,176 (10.89 per cent) had nutrition problems, 13,019 (3.71 per cent) risky behaviours, 7,938 (2.26 per cent) physical health problems, 3,099 (0.88 per cent) sexual reproductive health and 2,329 (0.66 per cent) with mental health problems (Figure 100). 46,527 of the adolescents were required to have further intervention either from the Family Medicine Specialist, Medical Officer, Dietitian, Counsellor or Social Welfare Officer. The current number of health clinics providing adolescent health services is 1,016 clinics nationwide.
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Figure 99
Number of Adolescent Population (10-19 years) Screened, Malaysia 2015-2019
Source: Health Informatics Centre, MOH (2015-2019)
*Preliminary Data 2019. In general, the number of adolescents screened each year has exceeds the target of 5 per cent of total Malaysian adolescent population.
Figure 100
Adolescent Health Morbidity Trend 2015-2019, Malaysia
Source: Health Informatics Centre, MOH (2015-2019)
*Preliminary Data 2019.
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11.2 Sexual and Reproductive Health Services Coverage
11.2.1 Teenage Pregnancy
Indicators for teenage pregnancy generally have shown decline trends. New antenatal cases among adolescents registered in the MOH primary health care facilities have declined from 18,847 (2012) to 10,349 (2019) (Figure 101). It is also shown that 6,186 (59.8 per cent) adolescents were married and the remaining 4,163 (40.2 per cent) were unmarried.
Figure 101
Number of New Antenatal Cases Among Adolescents (10-19 year old)
Registered at the MOH Primary Health Care Facilities
and Marital Status, Malaysia 2011-2019
Source: State Health Department, MOH (2011-2019)
The decline in number of new antenatal cases among adolescents in MOH facilities conforming the adolescent live birth by the Department of Statistics, which also shows a decline of 19,511 (2011) to 12,793 (2017).
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Majority of adolescents aged 15-19 year old (84.4-95.7 per cent) sought antenatal treatment from MOH healthcare facilities. Only about 20 per cent went to private clinics. This shows that the MOH provides access to all without discrimination.
Figure 102
Number of New Antenatal Cases among Adolescents (10-19 year old) Registered at the MOH Primary Healthcare Facilities and Schooling Status, Malaysia 2013-2019
Source: State Health Department, MOH (2013-2019)
Although the number of pregnant teenagers not attending school is declining, the percentage remains high every year at around 80 per cent. In 2019 8,298 (80 per cent) were no longer in school while 2,051 (19.8 per cent) were still in school (Figure 102).
MOH has provided a specific referral form for adolescents who wish to continue schooling after giving birth. The effort is to reduce dropout among pregnant teenagers from education that is crucial for their future. This matter has been discussed at the National Social Council for comprehensive measures in addressing issues related with teenage pregnancy covering health, welfare, education and more.
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Table 64
Number of New Antenatal Cases Among Adolescents (10-19 year old) Registered at the MOH Primary Healthcare Facilities by States, Malaysia 2019
Teenage Pregnancy (10-19 years old) Total Number New Cases of Antenatal State Married Unmarried Total
Perlis 82 49 131 3972
Kedah 255 175 430 30747
Pulau Pinang 148 124 272 20142
Perak 469 297 766 29012
Selangor 417 475 892 99668
Negeri Sembilan 364 342 706 17238
Melaka 113 95 208 14762
Johor 400 479 879 58151
Pahang 765 142 907 25640
Terengganu 373 60 433 24462
Kelantan 503 91 594 25548
Sarawak 723 1244 1967 35856
Sabah 1414 410 1824 48114
WP Kuala Lumpur 119 152 271 21443
WP Putrajaya 2 5 7 2911
WP Labuan 39 23 62 1962
Total 6186 4163 10,349 459628
Source: State Health Department, MOH (2019)
Table 64 looks into the number of teenage pregnancy by states in 2019 which Sarawak has the highest number (1,967 cases) followed by Sabah (1,824 cases), Pahang (907 cases), Selangor (892 cases) and Johor (879 cases).
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11.2.2 Age Specific Fertility Rate (ASFR)
Figure 103
Age Specific Fertility Rate (ASFR) Among Adolescent Girls 15-19 Year Old,
Malaysia 1991-2018
Source: Department of Statistics Malaysia (1991-2018)
Age Specific Fertility Rates (ASFR) among adolescent girls (15-19 year old) have decreased from 28/1000 per population (1991) to 8.5/1000 (2018) (Figure 103). The decline reflects the efforts that have been done by various stakeholders in dealing with teenage pregnancy.
The Adolescent Friendly Health Services are being strengthened and access to the service is enhanced at all government primary healthcare facilities throughout the country. Adolescents’ and healthcare providers’ awareness on sexual and reproductive health continues to be enhanced through efforts that involve government and non-government organizations platforms such as Ministry of Education, National Population and Family Development Board (LPPKN), Federation of Reproductive Health Associations Malaysia (FRHAM), Malaysian Association for Adolescent Health (MAAH) etc.
11.3 Generasiku Sayang (Love My Generation)
The Generasiku Sayang (GKS) programme was launched on October 29th 2015 and patronized by Her Majesty Raja Zarith Sofiah, the Queen of Johor. The program is another initiative of MOH aimed at assisting the adolescents in:
● Providing protection as well as care during pregnancy and after birth in ensuring the health, safety and welfare of the mother and baby 164
● Providing support, guidance and rehabilitation towards achieving a better life physically, mentally, socially and spiritually ● Providing integrated and holistic interventions via smart partnership of government, private agencies and NGOs ● Reducing stigma among the public so the adolescents are well supported and not excluded in line with Sustainable Development Goals which is inclusive development for all without marginalizing any group – 'inclusive and leaving no one behind'.
The Generasiku Sayang programme is still well implemented and currently Johor, Kelantan and Terengganu have established the GKS Center, while Sarawak and Perak have set up a ‘One Stop Teenage Pregnancy Committee’ (OSTPC). Other states have adapted the program into collaboration with state Islamic Religious Councils, NGO shelters etc.
11.4 Common Causes of Morbidity in Adolescent
Table 65 and 66 describe the top morbidities among adolescents in details. The leading cause of hospitalization among male adolescents were ‘injury, poisoning and certain other consequences of external cause’ - 32.1 per cent while for female adolescents were ‘pregnancy, childbirth and the puerperium’ - 29.6 per cent (Table 2).
Table 65
Top 10 Common Causes of MOH Hospital Admission Among Adolescent (12-19 Years) by Sex, 2018
Male Female DETAILED CAUSE DETAILED CAUSE Percentage Discharges Percentage GROUPS Discharges (n) GROUPS (%) (n) (%)
1 Injury, poisoning and 22,267 32.1% Pregnancy, 21,655 29.6% certain other childbirth and the consequences of puerperium external causes
2 Certain infectious and 10,807 15.6% Certain infectious 7,930 10.8% parasitic diseases and parasitic diseases
3 Diseases of the 7,182 10.4% Diseases of 7,355 10.1% respiratory system The Respiratory System
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Male Female DETAILED CAUSE DETAILED CAUSE Percentage Discharges Percentage GROUPS Discharges (n) GROUPS (%) (n) (%)
4 Diseases of the 5,591 8.1% Injury, poisoning 7,064 9.7% digestive system and certain
Other consequences of external causes
5 Diseases of the blood 3,518 5.1% Diseases of the 5,570 7.6% and blood-forming digestive system organs and certain disorders involving the immune mechanism
6 Diseases of the 2,717 3.9% Diseases of the 4,414 6.0% genitourinary blood and blood- forming organs and System certain disorders involving the immune mechanism
7 Diseases of 2,530 3.6% Diseases of the 3,287 4.5% genitourinary The nervous system System
8 Factors influencing 2,477 3.6% Factors influencing 2,753 3.8% health status and health status contact with health and contact with services health services
9 Neoplasms 2,328 3.4% Symptoms, signs 2,283 3.1% and abnormal clinical and laboratory findings, not elsewhere classified
10 Symptoms, signs and 2,007 2.9% Neoplasms 2,168 3.0% abnormal clinical and laboratory findings, not
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Male Female DETAILED CAUSE DETAILED CAUSE Percentage Discharges Percentage GROUPS Discharges (n) GROUPS (%) (n) (%)
elsewhere classified
TOTAL 61,424 TOTAL 64,479
(Out of 20 morbidity) (Out of 20 morbidity)
Source: Health Informatics Centre, MOH (2018)
Table 66 shows the top causes of adolescent outpatient attendance in public healthcare facilities. The main cause for male adolescents (51.3 per cent) and females (49.8 per cent) were the same which is related to diseases of the respiratory system.
Table 66
Top 10 Morbidity for Outpatient Attendance in Public Health Facilities Among Adolescent (10-19 Years) by Sex, 2018
Male Female
No. Morbidity Number Percentage Morbidity Number Percentage
(n) (%) (n) (%)
1 Diseases of the 971,259 51.3% Diseases of the 996,289 49.8% respiratory system respiratory system
2 Symptoms, signs and 217,307 11.5% Symptoms, signs and 247,623 12.4% abnormal clinical and abnormal clinical and
laboratory findings, laboratory findings, not elsewhere not elsewhere classified classified
3 Factors influencing 130,098 6.9% Factors influencing 142,932 7.2% health status and health status and
contact with health contact with health services services
4 Diseases of the Skin 115,451 6.1% Disease of digestive 133,693 6.7%
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Male Female
No. Morbidity Number Percentage Morbidity Number Percentage
(n) (%) (n) (%)
and Subcutaneous system
Tissue
5 Disease of digestive 112,033 5.9% Diseases of the Skin 111,962 5.6% system and Subcutaneous Tissue 6 Certain infectious and 108,128 5.7% Certain infectious 93,498 4.7% parasitic diseases and
parasitic diseases 7 Injury, poisoning and 86,293 4.6% Injury, poisoning and 57,562 2.9% certain other certain other
consequences of consequences of external causes external causes
8 Diseases of the eye 51,458 2.7% Diseases of the eye 51,843 2.6%
and adnexa and adnexa
9 Diseases of the 33,760 1.8% Disease of the 39,615 2.0% Musculoskeletal genitourinary system System and Connective Tissue
10 Diseases of the ear 33,548 1.8% Diseases of the ear 36,397 1.8%
and mastoid process and mastoid process
Total (Out of 20 1,859,335 Total (Out of 20 1,911,414
morbidity) morbidity)
Source: Health Informatics Centre, MOH (2018)
11.5 Adolescent Friendly Health Services Best Practice
One of the core programme for the Adolescent Health Sector 2019 Plan of Action is to strengthen Adolescent Friendly Health Services (AFHS) at selected health clinics as Adolescent Friendly Health Services Best Practice. It aims to serve as a quality benchmark that meets the WHO-defined Adolescent Friendly Health Services criterias.
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A total of 38 clinics nationwide have been selected and services were strengthened towards adolescent- friendly in line with the WHO and SOP criteria provided by the MOH. Awareness on the importance of adolescent health and adolescent friendly health services were heightened among healthcare providers for early detection and intervention in achieving lower morbidity and mortality among adolescents.
A series of meetings with state representatives were held to develop the AFHS assessment / checklist in accordance with the WHO Criteria and MOH guidelines as well as identify the monitoring team in each state. Guidance with guidelines and briefings were given to ensure the smoothness of assessment process.
Health clinics that has been selected to implement Adolescent Friendly Health Services and that has met the criterias outlined by WHO were assessed and graded based on the following 5 components:
1. Clinical management commitment to adolescent health services 2. Commitment of health personnel 3. Optional activity 4. Innovation/ creativity/ research 5. Inter & intra-agency collaboration.
Assessment of AFHS Best Practice clinics were done by a monitoring team comprising of representatives from FHDD (Adolescent Health Sector) and representatives from State Health Department (Public Health Physician, Family Medicine Specialist Physicians, Senior Assisstant Medical Officer and Senior Nurse). All 38 health clinics were evaluated over the period of June to December 2019.
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Table 67
AFHS Best Practice Clinics 2019
No. Number of Per cent Ranking Description Health Clinic (%)
1. 20 52.6 Best Practice + Innovation 2. 14 36.8 Best Practice 3. 4 10.5 Recognition Best Practice may be considered after improvement
4. - - Need further improvement 5. - - Failed to comply with Best Practice
minimum requirements
Source: Family Health Development Division, MOH (2019)
Among the criterias assessed are commitment, competency, confidentiality, being non-judgemental, sensitive and providing care in the best interest of the child. Services provided should be with quality and comprehensive including aspects of health promotion, screening, advice & counseling, early intervention and referral. In addition, the involvement of adolescent, community, clinic advisory panels and inter / intra-agency collaboration in health promotion and intervention were also observed.
From the assessment, 34 health clinics (89.4 per cent) have achieved 4 and 5 stars rating. Among the implementation success are:
● Increased awareness, knowledge, attitude and skill of healthcare providers in managing adolescent health ● Strong commitment from managers at all levels (state, district & clinic) ● More adolescent friendly work process and environment created (dedicated team/ space/ ‘person in charge’) ● Actively involving the adolescents in various clinic programs and activities ● Creative and innovative approaches involving peer, community, social media and ICT ● Improved intra & inter sectoral collaboration (Health Clinic Advisory Panel/ School Counselors/ public and private higher educational institutions/ NGOs etc) ● Good inter-agency linkage (referral) system
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Implementation challenges:
● Integrated services (AFHS visibility) ● Low priority and working in silos ● High turn over staff (new staff are not trained) ● Limited human resources, work space and budget constraint ● Incomplete data collection (cencus / reten) ● Supervisory role is still not optimized ● Adolescents & parental support issues (self stigma, transportation, referral from schools, parental consents etc.)
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11.6 Networking with other Agencies and NGOs
Ministry of Health has established the National Adolescent Health Technical Committee chaired by Deputy Director General (Public Health) since 2008. The objective is to discuss the current adolescent health issues and monitor the implementation of National Adolescent Health Policy and Plan of Action 2015-2020. The committee meets twice a year and comprises of various government and non- government agencies such as the Ministry of Education (KPM), Ministry of Women, Family and Community Development (KPWKM), Ministry of Youth and Sports (KBS), Malaysian Communications & Multimedia Commission (SKMM), Department of Islamic Development (JAKIM), Federation of Reproductive Health Associations (FRHAM), Malaysian Association of Adolescent Health (MAAH), university and youth representatives etc.
The committee have succeeded in addressing few issues and they were presented at the National Social Council, State Ministers / Chief Ministers Meetings as well as Council of Rulers Conference resulted in several new policy decisions. Teenage pregnancy, bully, high risk behaviors and parenting skills are among social issues that were highlighted in the meeting. MOH continues to work via smart partnership of various government and private agencies in advocating and implementing the National Adolescent Health Policy and Plan of Action covering 7 strategies and 5 scopes of Physical Health, Nutrition, Mental, Sexual & Reproductive Health as well as Risky Behaviours.
11.7 Human Resources and Training
In 2018, several series of national trainings and workshops that involved more than 500 healthcare providers from various categories were held:
1. Mesyuarat Memperkasa Perkhidmatan Kesihatan Remaja Peringkat Kebangsaan 2019 on March 18-20 2019 in Klang, Selangor with 70 participants. The objective is to strengthen and enhance the knowledge, attitudes as well as basic and adolescent counselling skills of healthcare providers at primary health level (Image 10). 2. 15th National Symposium on Adolescent Health on April 4-6 2019 in Sultanah Bahiyah Alor Setar Hospital, Kedah with participants. MOH has contributed in this symposium organized by the Malaysian Association for Adolescent Health (MAAH). It aims to update knowledge on adolescent health issues among healthcare providers and those involved in dealing with adolescents (Image 11). 3. Persidangan ‘Understanding and Shaping Adolescents Towards Excellence’ Peringkat Kebangsaan on 2 Julai 2019 in Parcel E Auditorium, Putrajaya with 250 participants. Participants were introduced with the concept of Shaping Excellent Character, aiming at enhancing the knowledge, attitude, skills as well as psychological and communication basics among healthcare providers in managing the adolescents (Image 12).
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4. Taklimat Reten Borang Saringan Status Kesihatan (BSSK) Peringkat Kebangsaan on August 26 2019 in BPKK, KKM with 30 participants. It aims to enhance reten/cencus management, quality data analysis and precise reporting (Image 13). 5. Seminar Pencegahan Jenayah Seksual Kanak-Kanak dan Remaja Peringkat Kebangsaan “Lindungi & Kasihi Saya” on October 30-31 2019 in AADK Auditorium, Bangi Selangor with 150 participants. Objective is to provide knowledge and skills to health professionals, counselors, NGOs and other relevant stakeholders in addressing adolescent sexual and reproductive issues (Image 14).
Image 10
Mesyuarat Memperkasa Perkhidmatan Kesihatan Remaja Peringkat Kebangsaan
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Image 11
15th National Symposium on Adolescent Health
Image 12
Persidangan ‘Understanding and Shaping Adolescent Towards Excellence’ Peringkat Kebangsaan
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Image 13
Taklimat Reten Borang Saringan Status Kesihatan (BSSK) Peringkat Kebangsaan
Image 14
Seminar Pencegahan Jenayah Seksual Kanak-Kanak dan Remaja Peringkat Kebangsaan ‘Lindungi & Kasihi Saya’
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11.8 Way Forward
A WHO global study has shown that 3 main protective factors for adolescents from getting involved in early sex, substance abuse and depression are connectedness to family, connectedness to school and religious beliefs. Hence, promotive and preventive efforts need to be focused on these 3 areas. In addition to the conventional methods, social media platforms also need to be optimized in line with the digital generation. MOH together with various stakeholders and agencies must work together in addressing the adolescent issues with comprehensive, effective, integrated and sustainable efforts. More creative and innovative strategies and programs are needed to make the most of the impact on the health and well-being of Malaysian adolescents.
12 ADULT HEALTH SERVICES
12.1 Background
The 1978 Alma Ata Declaration targeting Health for All by emphasizing primary health care has strengthened the government's commitment to continue improving the health of men and women in the country. Thus, in 1995, the Family Planning Unit, known as the Women's Health Unit, expanded its scope to cover reproductive cancer (breast and cervical cancer) screening as well as reproductive health activities including gender issues and violence against women. Furthermore, in 2008, "REAP or Reviewed Approach In Primary Health Care" was introduced to strengthened the adolescents, adults, elderly and people with special needs programmes as well as various prevention programmes such as cancer, hypertension, diabetes, tuberculosis, malaria, HIV and sexually transmitted diseases in health clinics. In line with the expansion of the scope of the unit which included health risk assessment for both men and women, the unit's name was converted to Adult Health Sector in 2009.
The Adult Health Sector is responsible in planning, monitoring and evaluating the performance and effectiveness of adult health programmes. These functions include:
1) Plan and develop health programmes for adults encompassing reproductive health, infectious and non-communicable diseases with a focus on health promotion and prevention. 2) Strengthening reproductive health activities especially reproductive cancers such as breast and cervical cancers. 3) Monitoring issues related to sexual and reproductive health of women and men. 4) Monitoring the health screening activities for both men and women
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12.2 Objectives
The Adult Health Sector aims to provide a gender-sensitive healthcare to enable adult men and women to achieve quality lives through health prevention and promotion activities with the involvement of various sectors.
12.3 National Cervical Cancer Screening Programme
Cervical Cancer Screening Programme Through Pap Smear
Pap smear was established in 1969 as a method of cervical cancer screening. It is an opportunistic screening programme targeting sexually active women aged 30-65 every three (3) years. Apart from the Ministry of Health Malaysia, other agencies involved are National Population and Family Development Board, University Hospitals, Clinics and Private Hospitals, Malaysian Armed Forces Hospitals and non- governmental organizations.
For monitoring purposes, the information related to each cervical cancer screening activity is recorded in the Pap smear register book and entered into an information online system. The data is periodically updated by the health clinic coordinators and reviewed by the District Health Offices. The Coordinator at the state level will verify the data before sending them to the Health Informatics Centre every three months. The Adult Health Sector will analyze and validate the data.
i. Pap Smear Coverage Figure 104 shows the five (5) year trend of Pap smear coverage conducted by all primary health facilities in Malaysia as reported to the Health Informatics Centre (PIK), Ministry of Health Malaysia. Initially, there was an increase in the coverage of the screening, but in the preceding three years, there has been a 5.8 per cent reduction in slide numbers compared to 2017. This decline is most likely to be closely linked to the shift in age of the Pap smear screening policy effective in 2018.
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Figure 104
Number of Pap Smear Slides Taken, 2015-2019
538,038 540,000 535,263 532,127
530,000
520,000
507,905 510,000 501,288 500,000
490,000
480,000 2015 2016 2017 2018 2019
Source: Health Informatics Centre, MOH
Figure 105 shows the percentage of Pap smear coverage for sexually active women aged 30 to 65 according to state. The five (5) year trend shows that states with small female population such as Perlis (38.4 per cent in 2019) and Penang (39 per cent in 2019) are on the verge of achieving their target of 40 per cent while Federal Territory of Putrajaya (122.5 per cent in 2019) exceeded the target. Instead, states with large female population such as Pahang, Selangor and Johor, did not show encouraging results. This may be due to shortage of human resources and equipment. In addition, in 2018, due to changes in the policy concerning the age range, a decrease in Pap smear coverage in almost all states of Malaysia except Perak, Selangor, Terengganu and Kelantan was observed. However, following intensification of health promotion activities, staff training and equipment supply in 2019, most states reported rise in Pap smear coverage.
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Figure 105
Percentage of Pap Smear Coverage for Women Aged 30-65 Years (by All Agencies) According to State, 2015-2019
140
120
100
80
60
40
20
0 Melak WP.La Perlis Kedah P.Png Perak WPKL WPPJ S'gor NS Johor Phg T'ganu K'tan Sabah S'wak M'sia a b 2015 35.1 24.2 34.9 25.6 27.6 31.1 17.5 27.3 16.9 22.8 24.7 19.6 21.4 30.9 16.8 30.4 23.1 2016 34.8 24.1 36.5 23 31.7 34.4 20.1 23.4 17 19.6 22.2 20.6 20 21.1 16.9 29.7 23 2017 37.18 24.57 45.81 24.4 33.14 38.47 25.18 29.76 30.2 21.48 23.08 23.11 20.9 25.77 17.8 31.4 26.3 2018 30.4 21.7 20.3 25.4 26.6 37.4 26.9 26.5 24.9 15.7 21.0 24.1 22.8 17.4 14.9 29.8 23.0 2019 38.4 24.5 39.0 27.8 25.2 122.5 24.4 30.3 31.0 15.2 21.3 27.4 30.2 16.3 12.6 28.0 24.5
Source: Health Informatics Centre, MOH (based on assumption, 1 slide represents 1 woman)
Pap Smear Screening According to Age Group
Figure 106 displays the number of women undergoing Pap smear tests by age group. This cervical cancer screening program is conducted in the Maternal and Child unit in the health clinics where most of the women attending the clinics are in the reproductive age group. From the analysis, women between the ages of 20 and 39 were the highest age group who underwent Pap smear screening, with 49.7 per cent to 52.3 per cent of all age groups from 2015 to 2019 belong to this age group. Pap smear screening in women above 50 years of age should be iintensified as these groups of women are at greater risk for developing cervical cancer. Promotional activities such as awareness campaigns on cervical cancer symptoms and availability cervical cancer screening at health clinics should be enhanced to encourage more women to undergo screening in order to prevent cervical cancer.
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Figure 106
Percentage of Pap Smear According to Age Group for 2015 to 2019
300,000
250,000
200,000
150,000
100,000
50,000
0 2015 2016 2017 2018 2019 20-39 years 269,575 278,158 275,647 251,902 239,932 40-49 years 123,889 123,878 124,181 122,394 119,106 50-64 years 115,167 127,721 111,481 109,534 109,706 ≥ 65 years 20,193 17,473 15,723 13,317 14,033
Source: Health Informatics Centre, MOH Denominator: Number of eligible women for the age group
Pap Smear Report According to Bethesda Classification System
The Bethesda Classification System has been adopted in Malaysia since 1999 to replace the CIN Grading Classification System. Positive detection rates show an increasing trend from 2015 to 2019 (Figure 107). The rate for this Malaysia is comparable to neighboring Thailand (1.6 per cent).
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Figure 107
Percentage of Smear Positive, 2015-2019
1.4
1.2
1
0.8
0.6
0.4
0.2
0 2015 2016 2017 2018 2019 Percentage (%) 0.85 0.94 0.94 1.14 1.22
Source: Health Informatics Centre, MOH
Atypical Squamous Cells of Undetermined Significance (ASCUS) was the most common finding among women who underwent Pap smear in 2019 with 42.4 per cent of slides reported as ASCUS (Figure 108). This were followed by Low Grade Squamous Intraepithelial Lesion (LGSIL) and High Grade Squamous Intraepithelial Lesion (HGSIL) at 27.1 per cent and 15.9 per cent respectively. Human Papillomavirus (HPV) was detected in 6.8 per cent of the slides while a lower percentage of the slides, 3.5 per cent were reported as Endocervical Adenoma in-situ (EIS). Adenocarcinoma and Squamous Cell Carcinoma were detected in 2.5 per cent and 1.8 per cent of the slides respectively.
Figure 108
Percentage of Positive Slides Results 2019
1.8% 2.5% 3.5% 6.8% 27.1%
42.4% 15.9%
LGSIL HGSIL ASCUS EIS SCC ADENO CA HPV
Source: Health Informatics Centre, MOH
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Quality Indicator
Unsatisfactory Slides
An unsatisfactory slide percentage of more than 2.5 percent is one of the quality indicators monitored for the Pap smear Screening Programme. Based on Figure 109, this indicator complies with the target set. During the five (5) year period, there was no significant change in this indicator. There are several actors affecting this indicator; operator’s skill required to perform the Pap smear, recklessness that might occur and the level of knowledge of healthcare staff.
Figure 109
Percentage of Unsatisfactory Slides, 2015-2019
Source: Health Informatics Centre, MOH
Absent endocervical cell
The presence of endoscopic cells is one of the determinants of Pap smear screening tests. The permissible percentage of absent endocervical cell slides is 20 per cent. Overall, Figure 110 shows that there has been improvement in the achievement of this indicator. Selangor, Sabah and Terengganu showed excellent performance and ranked in the top three compared to other states. However, Perlis, Perak, Kedah, Federal Territories of Kuala Lumpur and Putrajaya did not meet the target. There are several actors affecting this indicator; operator’s skill required to perform the Pap smear, recklessness that might occur and the level of knowledge of healthcare staff. 182
Figure 110
Trend of Absent Endocervical Cell Slides, 2015-2019
45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Perlis Kdh PP Prk WPKL WPP Sgor N9 Mlk Johor Phg Tgan Ktan WL Sbh Srwk Msia u 2015 31.4% 22.3% 16.3% 35.4% 8.5% 4.6% 17.4% 28.8% 14.9% 19.2% 31.7% 25.2% 33.2% 24.2% 19.2% 27.3% 23.5% 2016 36.4% 29.1% 8.2% 39.7% 22.3% 18.0% 14.9% 28.5% 12.1% 19.2% 32.9% 11.3% 28.7% 16.2% 21.0% 25.2% 23.4% 2017 27.4% 26.7% 3.9% 29.9% 28.9% 15.5% 13.6% 23.3% 10.8% 19.1% 20.2% 14.8% 19.6% 17.0% 19.9% 22.9% 15.9% 2018 20.7% 28.7% 8.6% 27.0% 42.7% 22.2% 9.3% 19.8% 14.8% 16.1% 17.5% 15.1% 16.3% 9.8% 15.9% 18.5% 17.6% 2019 22.2% 29.6% 18.1% 30.4% 33.9% 20.9% 7.5% 17.9% 15.5% 16.0% 15.6% 12.4% 13.3% 10.6% 10.7% 17.9% 17.0%
Source: Health Informatics Centre, MOH
Cervical Cancer Screening Programme Utilizing HPV DNA Test
In May 2018, the Director General of the World Health Organization (WHO), directed all countries to take immediate action to eradicate cervical cancer. The elimination of cervical cancer is defined as the incidence of less than 4 / 100,000 population. In Malaysia, the Family Health Development Division (FHDD) held a series of discussions on the implementation of the HPV test as a leading tool in cervical cancer screening beginning in 2018. Following the approval of the Mesyuarat Ketua Pengarah Kesihatan (KPK) Khas Bil. 3/2019 on June 24, 2019, a proposal to carry out the HPV test was presented to the Jawatankuasa Dasar dan Jawatankuasa Pemandu Perancangan KKM. Following approval, the BPKK conducted the Phase 1 HPV testing in four (4) states, Federal Territories of Putrajaya and Kuala Lumpur, Kedah and Kelantan in mid-August and September 2019. The service was conducted in outpatient units at primary health facilities and offered to sexually active women aged 30 to 49 years old. Women outside this age group were offered Pap Smear.
The data was entered in the HPV (Excel) Register where monthly ‘reten’ was generated automatically. In order to ensure a smooth implementation of the cervical cancer screening programme utilizing this HPV test, liaison officers were appointed for clinics, district health offices, state health departments and laboratories. This monthly ‘reten’ was sent through the clinics to the district health offices before reviewed by the state health departments. Next, the liaison officers at the state health departments sent the ‘reten’ to the Adult Health Sector for analysis. In addition to monitoring the’reten’, the Adult Health Sector also conducted supervision at health clinics to evaluate the running of the programme and discuss possible remedial measures if any difficulties arise. Supervision was also carried out in the
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laboratories to obtain a more detailed picture of the processes involved in sample analysis and to identify problems faced by the healthcare staff.
Since August 2019, the cumulative sample collected for the HPV test for Phase 1 was 22,073, which was 83.7 per cent of the target set (Figure 111). Compared to the target set for their respective states, it was found that Kedah had reached 95.3 per cent of its target, followed by Kelantan with 81.7 per cent, Federal Territory of Putrajaya with 79.1 per cent and Federal Territory of Kuala Lumpur with 79 per cent. Most states sought outreach activities in order to reach more women.
Based on the analysis, the total percentage of HPV self-sampling was 98.9 per cent, while staff-assisted sampling was 1.1 per cent. Majority of women who underwent HPV testing in all the four states were were found to be HPV negative (13,824 women or 94 per cent) (Figure 112). This group of women have been advised to repeat their test within 5 years. However, 192 (1.3 per cent) women had HPV 16/18 positive while 448 (3.0 per cent) women were high risk non-HPV 16/18 positive. These groups of women need further evaluation.
Figure 111
Number of HPV Tests Conducted in Phase 1, 2019
7,000 120%
6,000 100% 5,000 80% 4,000 60% 3,000 40%
No. No. of samples 2,000 Percetage achieved 1,000 20%
0 0% WPKL PUTRAJAYA KELANTAN KEDAH NUMBER 4,935 5,840 5,105 6,193 PERCENTAGE 79.0% 79.1% 81.7% 95.3% States
Source: Family Health Development Division, MOH
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Figure 112
HPV DNA Test Results Phase 1, 2019
13,824 (94%) 14,000
12,000
10,000
8,000
6,000
4,000
(3.0%) (1.7%) 2,000 448 192 (1.3%) 247 0 HPV Not HPV HR Non HPV 16/18 Unsatisfactory Detected 16/18 positive positive
Source: Family Health Development Division, MOH
12.4 The Way Forward in Cervical Cancer Prevention
By the year 2020, the Adult Health Sector plans to expand HPV testing to four more states, namely Penang, Selangor, Negeri Sembilan and Sarawak. A series of discussions were conducted in 2019 to plan the implementation of screening programmes using HPV testing in the designated four states. In addition, the procurement of equipment such as colposcopy was also incorporated in the projection. If the proposal for comprehensive budget is approved, the Adult Health Sector hopes to expand the programme throughout the country by 2023 and HPV testing will be a main screening tool in the cervical cancer screening programme.
12.5 Breast Cancer Prevention Programme
Breast cancer is the most cancer among women in Malaysia, according to the Malaysian National Cancer Registry Report (2012-2016). The incidence of breast cancer has increased from 31.1 / 100,000 population (2007-2011) to 34.1 / 100,000 population in 2012 to 2016. Most patients with breast cancer were diagnosed at stage two and above (82.4 per cent). According to the Malaysian Study on Cancer Survival 2018, breast cancer survival rate was 66.8 per cent in Malaysia. The survival rate is highly dependent on the stage of cancer. Thus, the Ministry of Health Malaysia has started a breast health awareness campaign since 1995 by encouraging women to conduct breast self-examination (BSE). Subsequently, in 2009, emphasis was placed on clinical breast examination (CBE) which is a modality for
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early stage breast cancer detection. Women who are found to have any abnormalities during the CBE will be referred for further management. Women with family history of breast cancer or risk factors for breast cancer, will be referred for mammogram examination.
The main objective of the breast cancer prevention programme is to improve early detection of breast cancer in enabling early treatment. Therefore, health personnel in rural and health clinics are encouraged to intensify efforts to raise awareness about breast cancer and the importance of conducting BSE. Health workers are also trained to empower women to take responsibility for their own health.
Clinical Breast Examination (CBE)
The National Technical Committee Meeting on Breast Cancer Prevention Programme held in November 2010 elected Clinical Breast Examination (CBE) as a screening modality for early detection and subsequently assisting in downstaging breast cancer. The implementation of the CBE grants health care providers the opportunity to provide women with health education concerning breast cancer, the importance of early cancer detection, cancer risk factors and breast cancer awareness. However, the sensitivity and specificity of these modalities are highly dependent on the skills and techniques of the healthcare personnel.
The CBE is an essential examination for female clients attending clinics. Frequency of conducting CBE is as follows:
● Women aged 20 to 39 years – 3-yearly ● Women aged 40 tahun and above – yearly ● Women with risk factors – yearly regardless of age
Data has been compiled since 2010 in order to monitor the effectiveness of screening through CBE. The target for CBE has been set at 25 percent for women aged 20 and above. The data is periodically updated by the health clinic coordinators and is reviewed by the District Health Offices and later verified by the State Department of Health Coordinators before it is sent to the Health Informatics Centre every three months. The Adult Health Sector will analyze and validate the data.
The percentage of CBE achievement among women aged 20 years and above has shown an increasing trend over the last five (5) years except in 2018, where the coverage has decreased slightly (Figure 113). Although the percentage of coverage has decreased in 2018, it has met the set target. This positive trend that surpasses the target set proves the heightened level of awareness and knowledge among women concerning the importance of CBE in early detection of breast cancer.
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Figure 113
Trend of Clinical Breast Examination Achievement, 2015-2019
30% 29.2%
29% 27.9% 28%
27% 25.8% 26% 25.0% 24.6% 25%
24%
23%
22% 2015 2016 2017 2018 2019
Source: Family Health Development Division, MOH 2015-2019
Figure 114
Percentage of Clinical Breast Examination in Health Clinics
According to Age Group, 2015-2019
80% 70% 60% 50% 40% 30% 20% 10% 0% 2015 2016 2017 2018 2019 20-39 years 69.0% 74.2% 71.5% 62.3% 73.3% > 40 years 7.5% 7.7% 1.0% 8.8% 2.7%
Source: Family Health Development Division, MOH 2015-2019
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Figure 114 displays the percentage of women undergoing CBE in health clinics nationwide for a period of five (5) years. The highest percentage was among women aged 20 to 39 where CBE achievement for these two age groups exceeded the target. This age group is a reproductive age group that often receives treatment in the mother and child clinic compared to women aged 40 and above.
Figure 115
Findings of Clinical Breast Examination According to Age Group, 2019
700,000 600,000 500,000 400,000 300,000 (0.22%) (0.16%) (0.26%) (0.38%) (0.45%) 200,000 Abnormal 100,000 Normal 0 20-29 30-39 40-49 50-59 60 ke atas Normal 608,385 651,408 254,743 124,730 75,025 Abnormal 1,327 1,047 651 469 336
Source: Family Health Development Division, MOH 2019
The abnormalities discovered during CBE did not show any remarkable differences according to age (Figure 115). Overall, for all ages, 0.22 per cent of breast examinations were found abnormal and referred for further management. The level of sensitivity of this examination is highly dependent on the skills and techniques of the health personnel. Therefore, health personnel working in the clinics especially in the mother and child clinics should always attend refresher courses to ensure their technique is accurate according to CBE guideline. In addition, supervision should be carried out regularly to monitor healthcare staff conducting CBE on the clients.
Mammogram Screening for High Risk Women
Based on the Guideline Implementation for Breast Healthcare in Low and Middle-Income Countries 2008 by Breast Health Global Initiative (BHGI), countries with limited resources are recommended to commence targeted screening, for example high risk women and at the same instance promoting breast cancer awareness and clinical breast examination service. In this regard, the Family Health Development Division has been implementing mammogram screening for high-risk women since 2012. These risk
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factors are based on the Clinical Practice Guidelines, Breast Cancer Management (Second Edition). The Health Clinic serves as the gateway for high-risk women before being referred for mammogram screening at:
● Government hospitals (34 hospitals with mammogram facility); ● Mammogram subsidy programme by the National Population and Family Development Board (NPFDB); ● Customers’ choice of private hospitals. Clients who meet the criteria for high-risk women will undergo breast cancer screening and if any abnormalities are detected, the client will be referred to a nearby Surgeon Clinic. On the other hand, if no abnormalities are detected during examination, the client will be given an appointment for a mammogram examination. If the mammogram report is normal, the client will be given a follow-up appointment. However, if the mammogram results are abnormal, the client will be referred for further treatment.
The client's mammogram result and the other pertinent information will be recorded in the High-Risk Client Register. This data will be generated as a ‘reten’ by the health clinic which will be sent to the district health office and to the State health department every three (3) months for analysis by the Adult Health Sector.
Figure 116
Mammogram Screening and Breast Cancer Detection, 2015-2019
25,000 30.00%
20,000
20.00% 15,000
10,000 10.00%
5,000
0 0.00% 2015 2016 2017 2018 2019 No. of women who 22,540 17,195 11,699 12,512 23,365 underwent mammogram Percentage of breast 0.35% 0.30% 0.98% 0.85% 0.71% cancer detected
Source: Family Health Development Division, MOH 2019
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The number of high-risk women undergoing mammogram screening is highly dependent on the number of women who come to the health clinics for breast cancer screening and the number of mammograms available. The number of women undergoing mammogram has shown an increasing trend since 2017. This shows that women's awareness concerning breast cancer is intensifying. Percentage of breast cancer detection in the preceeding years were relatively low with only 0.35 per cent and 0.30 per cent in 2015 and 2016 respectively. However, commencing from 2017 to 2019, breast cancer detection percentages increased slightly from 0.71 per cent to 0.98 per cent. According to the Malaysian National Cancer Registry Report (2012-2016), the incidence of breast cancer has increased compared to the incidence in 2007-2011. Thus, health professionals are required to intensify their efforts by promoting health education concerning breast cancer risk factors. Women need to be empowered with knowledge and awareness on breast self-examination and breast cancer to urge them to seek further assessment.
Figure 117
Percentage of BI-RADS Category from Mammogram Report, 2016-2019
90%
80%
70%
60%
50%
40%
30%
20%
10%
0% 2016 2017 2018 2019 BI-RADS 0 10.61% 7.30% 5.02% 15.90% BI-RADS 1-2 83.70% 84.16% 83.40% 76.41% BI-RADS 3 4.00% 5.09% 6.51% 4.67% BI-RADS 4-5 1.65% 3.30% 4.82% 2.87% BI-RADS 6 0.04% 0.15% 0.25% 0.15%
Source: Family Health Development Division, MOH 2016-2019
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BI-RADS stands for Breast Imaging Reporting and Database System, which is a scoring system for reporting mammogram results. Category 0 requires further examination, category 1 or 2 refers to normal results, category 3 refers to probability of normal findings, but there is a 2 percent risk of cancer (requires follow-up), risk of cancer for category 4 increases and category 5 means risk of cancer increases by over 95 percent. For category 6, this result is reserved for patients who have undergone biopsy and confirmed cancer. Based on the results obtained, the majority of women undergoing mammography obtained BI-RADS 1-2 ranging from 76.41 percent to 84.16 percent (Figure 117). The percentage of women with BIRADS 3-5 ranged from 1.65 percent to 6.65 percent, with no significant increase for 2016 to 2019.
12.6 The Way Forward For Breast Cancer Prevention Programme
In 2020, Breast Cancer Early Detection Plan of Action will be created by the Breast Cancer National Task Force, which targets downstaging of breast cancer. Several objectives have been proposed that include increase public awareness of breast cancer and early detection of breast cancer as well facilitate access to referrals, through a range of strategies that will be developed through the involvement of various agencies.
12.7 Health Risk Screening Programme
The Integrated Health Service concept aims to strengthen the delivery of primary health care system towards a fair and efficient health service through the use of optimal resources as well as focusing on the achievement of the defined goals. One of the strategies designed to ensure the optimal use of resources is through health screening.
According to the National Health and Morbidity Survey conducted by the Public Health Institute, the trend for chronic illness has shown an increase. For example, diabetes has increased from 11.6 per cent (National Health and Morbidity Survey, NHMS 2006) in 2006 to 15.6 per cent in 2011 (NHMS 2011) and continued to rise to 17.5 per cent in 2015 (NHMS 2015). However, based on the statistic reported in NHMS 2015, approximately 50 per cent of diabetics are unaware of their illness. Therefore, health screening plays an important role in identifying these problems earlier.
The Health Risk Screening Programme is a healthcare service in health clinics that focuses on early detection of risk factors and diseases to enable early intervention on risk factors and diseases as well as promoting awareness on health issues. This screening programme is a platform for a comprehensive health care. This activity has been commenced since 2008 at health clinics across the country to screen adult clients (both women and men) where screening targets are set at 5 per cent of the adult population by region.
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The screening is conducted through the Men's and Women's Adult Health Status Screening Form (BSSK) covering a range of chronic health issues, mental health, nutrition, physical activity and reproductive health and risk factors for women and men. After the client fills out the form, a physical examination is performed and a diagnosis is made. Appropriate intervention will be taken and follow-up will be provided if necessary. The data will be compiled at the district and state level. It will then be submitted to the primer health section, family Health Development Division. The adult health sector will extract and analysed the sex disaggregated of the adult health component. Supervision of health clinics is also carried out by the Adult Health Sector to ensure the smooth running of the BSSK Program.
Health Screening Coverage For Adult Men and Women
The trend of health screening for men and women for the past five (5) years shows a slightly different trend for both sexes (Figure 118). This scenario is closely related to men's 'health seeking behavior'. Many studies on 'health seeking behavior' among adult men have reported that most adult men will only seek health care after they have serious illnesses. This is one of the factors that explains the lower health screening percentage among adult males compared to females each year. In addition, the health personnel are also responsible with other programmes at the health clinics which consume their time. It is essential to ensure regular supervision by supervisors in order to safeguard the achievement of this goal.
Figure 118
Health Risk Screening Coverage For Men and Women, 2015-2019
6.0 5.1 4.9 4.9 5.0 4.7 4.0 4.9 3.6 4.0 4.5 4.5 3.0
% 3.0
2.0
1.0
0.0 2015 2016 2017 2018 2019
Women Men
Source: Health Informatics Centre, MOH 2015-2019
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Figure 119
Number of Health Screening Conducted Among Adult Men and Women, 2015-2019
450,000 400,000 350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 2015 2016 2017 2018 2019 Wanita 335,960 444,527 371,328 404,070 391,106 Lelaki 289,231 380,137 331,360 369,773 368,101
Source: Health Informatics Centre, MOH 2015-2019 Figure 119 displays a comparison of the total health screening of women and men. It was found that for the past the past five (5) years, a total of 1,946,991 adult women and 1,738,602 adult men were screened, whereby the the total male screened was 10.7 per cent lower compared to the number of women screened. This finding might be influenced by poor health seeking behavior among men and is closely linked to their masculinity and behaviors such as immunity to disease, a culture that considers men as head of the family and the need to be strong, fear of knowing the risk of disease and many other factors.
Figure 120
Percentage of Health Screening According to Gender, 2019
10 9 8 Target ≥ 5% 7 6 5 4 3
Percentage of Screening 2 1 0 WPP/ Tgan Pls Kdh PP Prk Sgor N9 Mlk Jhr Phg Ktan Srwk Sbh WPL KL u Women 8.7 4.6 5.6 4.3 3.9 4.2 5.1 5.9 4.4 8 5.3 4.6 6.6 4.1 6.5 Men 7.7 4.1 5.6 4.3 3.8 4 4.6 6 3.6 7.6 5.1 4.1 5.2 3.8 3.1
Source: Health Informatics Centre, MOH 2019 193
Based on Figure 120 above, several states have demonstrated excellent health screening achievement for both sexes such as Perlis, Penang, Melaka, Pahang, Terengganu and Sarawak. However, most other states achieved lower screening percentage for men compared to women. All states have intensified their efforts to increase health screening performance especially among adult men through outreach activities, however, most of the response to this outreach activities were from women. Therefore, healthcare professionals are required to be more creative in expanding their activities to government and private offices in collaboration with non-governmental organizations to intensify health screening among adult men.
Health Risks Identified in Men and Women
Figures 81 and 82 display the trends of major health risk factors detected in men and women from health screening conducted from 2016 to 2019. Overall, the main risk factors detected for men and women such as smoking, weight problems, physical inactivity and unhealthy nutrition are risk factors for non-communicable diseases such as diabetes, hypertension and cardiovascular disease. These are modifiable risk factors whereby interventions should be undertaken to prevent individuals from being diagnosed with non-communicable diseases. Over the period of five (5) years, most of these risk factors for both gender have shown a significant decline. For men, smoking, physical inactivity and unhealthy eating habits have been reduced by more than 50 per cent in 2019. The efforts of healthcare professionals in reducing weight problems have successfully decline among men by 23.3 per cent for overweight and 5.5 per cent for obesity. For women, 59 per cent of physical inactivity and 40.9 per cent of unhealthy nutrition have successfully reduced in 2019. Although overweight has successfully reduced in 2019, the percentage of obese women has increased slightly. Compared to 2016, abnormal glucose levels have reduced by 68.8 per cent, but the percentage of women with hypertension remained status quo in 2019. Health education needs to continue in order to increase public awareness on the risk factors for non-communicable diseases.
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Figure 121
Top Six Risk Factors in Men, 2016-2019
25%
20%
15%
10%
5%
0% 2016 2017 2018 2019 Smoking 24.0% 23.6% 16.0% 9.8% Overweight 18.0% 23.0% 20.0% 13.8% Obese 7.1% 7.3% 8.0% 5.5% Physically Inactive 11.0% 12.9% 7.9% 4.7% Unhealth Eating Habit 7.3% 8.4% 5.7% 3.5% Hypertension 3.9% 5.5% 4.2% 3.9%
Source: Health Informatics Centre, MOH 2016-2019
Figure 19
Top Six Risk Factors in Women from 2016 to 2019
30%
25%
20%
15%
10%
5%
0% 2016 2017 2018 2019 Overweight 20.7% 16.4% 27.0% 13.5% Physically Inactive 16.1% 12.4% 15.0% 6.6% Obese 6.6% 8.8% 14.0% 6.9% Unhealthy Eating Habits 6.6% 8.9% 9.0% 3.9% Abnormal Glucose Level 10.9% 8.1% 7.0% 3.4% Hypertension 5.0% 3.8% 5.0% 2.5%
Source: Health Informatics Centre, MOH 2016-2019
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12.8 Activities and Achievement of Men’s Health Services
The Inaguration Ceremony of The National Men’s Health Plan of Action 2018-2023
Malaysia is the fifth country in the world to address men's health issues using national strategies. The Adult Health Sector is responsible for the planning, management and implementation of these policies taking into account data on male health in Malaysia.
The Adult Health Sector, Family Health Development Divison, held its Inaguration Ceremony of The National Men’s Health Plan of Action 2018-2023 on 30 October 2019 at the Auditorium Ministry of Home Affairs, Putrajaya. YB Dr. Lee Boon Chye, Deputy Minister of Health officiated the ceremony and launched the National Men’s Health Plan of Action 2018-2023. In his inaugural address, he emphasized the need to focus on men’s health. The National Men’s Health Plan of Action provides a working framework in promoting gender equity as well as improving the quality of life and health of men.
Approximately 600 participants from the whole country attended the event, which comprised State Health Directors, Deputy State Health Directors (Public Health), Assistant Medical Officers, nurses as well as representatives from other related agencies such as Ministry of Youth and Sports and Ministry of Women, Family and Community Development. The Adult Health Sector had successfully collaborated with Assistant Medical Officers from Family Health Development Divison and Persatuan Pembantu Perubatan Malaysia.
The purpose of this event was to provide information and increase the awareness of healthcare providers concerning the implementation of a dedicated Men's Health Service in Malaysia as well as to obtain views and suggestions from healthcare providers working on the field.
Several speakers who are well versed in men’s health were invited to give talks to the audience. Dr. Husni Bin Hussain, Family Health Consultant presented a broad overview on men’s health in Malaysia while Dr. Zakiah Binti Mohd Said, Public Health Physician shared the strategies lined in the Plan of Action. A very entertaining forum entitled ‘Sayang Tapi Melayang’ which was moderated by Dr. George G. Mathew, Family Health Consultant and attended by two exteemed specialists in Men’s Health; Dr. Mohd Ismail Mohd Thambi, Andrologist and Dato’ Prof. Dr. Zulkifli Bin Md Zainuddin, Urologist was held.
196
Image 15 Imej 16
Attendance of guests at the ceremony YBMK Dr. Lee Boon Chye officiating the ceremony
Source: Adult Health Sector, Family Health Development Division, MOH
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Monitoring of Men’s Health Services
Figure 123
Percentage of Erectile Dysfunction Among Diabetics, 2017-2019
14.53 16
14 10.93 10.13 12
10
8
% % CaseED 6
4
2
0 2017 2018 2019
Source: NDR Data, NCD, MOH 2017-2019
Figure 123 shows the prevalence of erectile dysfunction (ED) among diabetic patients for the years 2017 to 2019. However, based on a cross-sectional study, the prevalence of ED among diabetic patients in Malaysia was 89.2 per cent, which was higher compared to the figures reported in the figure above. Some men do not share their symptoms with health professionals because they consider this problem too personal and misbelieve that there is no cure for this condition. Awareness about ED needs to be heightened in men in order to persuade them to seek treatment as ED affects their quality of life.
198
Figure 124
Percentage of Death among Male in MOH Hospitals According to Diagnosis, 2018-2019
10% 9% 8% 7% 6% 5% 4% 3% 2% 1% 0% Malignant Mental and Other disorders Hyperplasia of neoplasm of behavioural of urinary system prostate prostate disorders 2018 9.02% 4.78% 1.32% 0.46% 2019 8.10% 3.48% 0.88% 0.41%
2018 2019
Source: Health Informatics Centre, MOH
Prostate cancer is one of the leading cause of death among hospitalized men in 2018 and 2019 (Figure 124). However, the percentages of men's death in 2019 due to prostate cancer, urinary system problems, benign prostatic hyperplasia and mental disorders were found to be lower compared to 2018. This decline may be due to increased screening and health education by health personnel that enable for early intervention.
The Way Forward For Men’s Health Service
In year 2020, in respect to men’s health service, the Adult Health Sector will focus on male reproductive health. The first approach in this area is developing a male health screening method specifically screening for lower urinary tract symptoms (LUTS).
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13 HEALTH SERVICES FOR PERSONS WITH DISABILITIES (PWDs)
The World Health Organization (WHO) Report on Disability estimates that 10-15 per cent of population in every nation has a disability and as such, there may be close to 3.2 million in Malaysia. With the increase population lifespan and rising numbers of elderly people, more individuals will be at risk for age-related disabilities.
The Ministry of Health Malaysia (MOH) has been providing health services to every level of population without prejudice, including to the disabled as to ensure that optimal health care is delivered to each and everyone. Integrated and holistic health services offered enclose every aspect such as health promotion, activities on prevention of disability, early screening and early detection of disability, early intervention and treatment, habilitation and rehabilitation, early referral to respective specialties, caregiver support and much more. Health care programmes for PWDs were planned and implemented in line with The Plan of Action of Health Care for PWDs 2011-2020, National Plan of Action for PWD 2016- 2022, PWD Act 2008, The Convention on The Rights of PWD 2008, Malaysian Plan (RMK) and The WHO Global Disability Action Plan 2014-2021.
13.1 Health Service for Children
Early Detection of Disabilities
Health services for children offered in government health clinics include growth and developmental assessment, health screening for early detection and risk of disability, nutritional status assessments and immunization. Any child who is diagnose having developmental delay or suspected with disability are given prompt stimulation and early intervention, early referral to a Medical Officer or a specialist for further investigation, rehabilitation and early treatment. In addition, health services for children with special needs (CWSN) has been extended to the community through outreach programs at the Community-Based Rehabilitation Center (CBR) and institutions under the perview of the Department of Social Welfare Malaysia, at schools and patient’s home.
As been reported yearly, there was an uptrend and increasing number of children diagnosed with disabilities at various ages. The monitoring of the indicator 'Percentage of Early Detection of Disability in Children Age 0-1 years old' marked to increase every year. This is due to the MOH's high commitment to conduct screening and early detection at various level. Detection of disabilities has to be carried out as early as possible so that early intervention and rehabilitation can be delivered promptly to minimize disabilities and complications due to long-term effects.
200
Involvement of all parties in health care for children especially the CWSN is very crucial. Empowerment and full commitment of parents / caretakers, family members, health care providers, relevant ministries and agencies, as well as non-government organizations are critical to support the survival of children with special needs in all aspect.
Figure 125
Trend of Percentage Detection of Disabilities Among Children Age 0 to 1-Year-Old, Malaysia 2015-2019
TARGET 0.12%
Source: Sistem Maklumat Pengurusan Kesihatan : Laporan Bulanan/Tahunan Kanak-kanak Berkeperluan Khas yang Dikesan Ketidakupayaan, Berumur 0-18 tahun (Malaysia, Year 2015-2019)
Figure 126
Trend of Percentage of Children Age 18 And 36 Months Old Suspected With Autism, Through Screening Using M-Chat, Malaysia 2016-2019
Source: Buku Daftar Jagaan Kesihatan Kanak-kanak (KKK101 Pindaan 2/2007) (Malaysia, Year 2016-2019)
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Sexual and Reproductive Health for Children with Disabilities
Children are vulnerable group that need to be protected and held accountable to each person in the community. This group more over children with disabilities are more easily exploited and exposed to various forms of abuse, especially sexual abuse. As such, the awareness on sexual dan reproductive health should be strengthen in order to educate all children expecially children with disabilities, as well as their parents, family members, caretakers and the community on this knowledge. Awareness on the aspects of health, personal hygiene, personal safety, human reproductive development, communication skills, sociocultural and spiritual development need to be nurtured and taught as early as possible.
The Ministry of Health Malaysia has initiated the awareness program on sexual health of children with disabilities, since 2010, adopting a training module titled ‘Training Module Reproductive Health for Children and Adolescents with Disabilities - Live Life, Stay Safe’. This module was developed as a reference material for the health care providers, carers and those providing services for children with disabilities.
This module focuses on the knowledge and skills of life management related to sexual health and personal safety such as understanding of the body parts concerning public and private concepts, sexual secondary changes of the body, circle of relationship, safe and unsafe touch, feelings and emotions, and so on, to be taught to children with special needs.
In 2019, several training were conducted for 225 health professionals and special education teachers throughout Malaysia using this module training. Each year, MOH conducted training to health care providers and special education teachers in delivering knowledge of sexual and reproductive health to children with special needs, with the purpose to help them to identify and reduce the risk of challenging behaviors among special needs student, that were frequently reported in school such as masturbation, nudity, sodomy and much more. The teachers were also taught the correct technique to approach the student and to offer help in various method.
13.3 Health Service for Adult PWDs: Domiciliary Health Care Services (DHC) and Palliative Care in Primary Healthcare
This health service is dedicated to stable bed-ridden patients who has been discharged from hospital and requires continuous care. The service rendered at the setting of patient’s home and delivered by a team of multi-disciplinary health personnel from a nearby health clinic. Among the care provided are rehabilitation to improve the quality of life of the patients, nursing care, as well as support to the
202
caregivers/family members in terms of education on basic care of the patient. Since its introduction in year 2014 to date, 14,099 patients across Malaysia have benefited from this service, of which 70 per cent are elderly.
In year 2019, a total of 2,585 new patients were enrolled in the program. Five (5) main diagnoses reported were stroke (1,527 cases), traumatic brain injury (193 cases), spinal cord injury (42 cases), cerebral palsy (16 cases), cancer (134 cases) and other diagnoses (673 case). Of these numbers, 1,817 patients were elderly. A total of 12,885 home visits were delivered by the multidisciplinary health team, in which 44,113 were for clinical care, 7,992 rehabilitation and 9,772 laboratory tests were conducted. 1,047 patients were discharged from this service and successfully taken over by their families, within 3 months of service provided.
Figure 127
Number and Percentage of Cases by Diagnosis,
Enrolled in Domiciliary Health Care Services, Malaysia 2016-2019
Source: Sistem Maklumat Pengurusan Kesihatan: Laporan Bulanan/Tahunan Perkhidmatan Perawatan Domisiliari di Kesihatan Primer, (Malaysia, Year 2016-2019)
203
Figure 128
Number of Interventions Given to Patients
Enrolled in Domiciliary Health Care Service, Malaysia 2016-2019
Sour ce: Sistem Maklumat Pengurusan Kesihatan: Laporan Bulanan/Tahunan Perkhidmatan Perawatan Domisiliari di Kesihatan Primer, (Malaysia, Year 2016-2019)
Palliative care has been recognized as one of the crucial component of comprehensive health care that need to be implement in every level of healthcare including in the community, as emphasized in a resolution by World Health Organization (WHO). In line with the recommendations and health transformation, MOH has integrated palliative care into the existing healthcare system as a fundamental strategy for universal health coverage in Malaysia.
Through the Domiciliary Health Care Services (Perkhidmatan Perawatan Domisiliari – PPD/DHC) in primary healthcare initiated in year 2014, palliative care element has been incorporate in the program since year 2016. There are currently 160 health clinics across Malaysia providing nursing care and rehabilitation to bed ridden patients at their home. Starting year 2016, selected health clinics in Selangor state that runs the DHC program, has piloted the palliative care element. The expansion of palliative care services implemented in stages based on the availability of resources and expertise, focusing on states with resident Palliative Medicine Specialists. As of December 2019, 39 health clinics in the states of Selangor, Kedah, Perak and Pulau Pinang have initiated the palliative care services. 204
In contrast to the scope of nursing care and rehabilitation, the palliative care element emphasized on improving the quality of life of patients diagnosed with cancer and chronic disease (non-cancer). Through the prevention and treatment of pain, relief of suffering by means of early identification and impeccable assessment, psychosocial, spiritual and various aspects of support, patients will be encouraged to live actively to the end of their life. In additional, emotional support for the carers and family members of the patient will be provided throughout this service and even after the departure of the patient.
In year 2019, MOH has launched the National Palliative Care Policy and Strategic Plan, which emphasized the role of palliative care in the community and highlighted various actions to strengthened the palliative services in every aspect and level of healthcare in Malaysia.
13.4 Health Services in the Community: Outreach Program to the Community- Based Rehabilitation Centre (CBR)
Health care services are also extended to the community in collaboration with various government agencies. To ensure holistic health services being provided to the vulnerable group, MOH has expanded its outreach services to the PWDs who attend the Community-Based Rehabilitation Center under the Community Welfare Department of Malaysia. This special program known as "PDK Ku Sihat" emphasizes on healthy lifestyle practices including healthy eating and nutritional balanced regime, consistent physical activity among PWDs and the CBR staff, as well as training the CBR staff to empower them in delivering proper care to the PWDs.
The services provided in the CBR are health screening to every PWDs in the CBR, early intervention, rehabilitation on fine motor and gross motor, exercises, activities of daily living skills, nutritional advice, vocational training and screening for readiness to school and others. CBR staf were also trained to conduct basic exercise with the PWDs.
In 2019, all 542 CBR were visited by a multi-disciplinary team from the nearby health clinics. A total of 19,105 (90 per cent) PWDs were screened for their health status, to identify the risk of non- communicable disease (NCD) especially among adult with disabilities. Health screening allows PWDs who were diagnosed or at risk of NCD, being referred immediately to respective multi-disciplinary team for further investigation, counseling, nutritional and diet modification, and much more.
205
Figure 129
Interventions Delivered to PWDs
in Community-Based Rehabilitation Center (CBR), Malaysia 2019
Source: Reten Bulanan/Tahunan: PDK 201A/Pind. 2017 (Year 2019)
13.5 Rehabilitation Services At Primary Health Care
Rehabilitation services in primary health care have been revised to strengthen its service delivery in accordance with the 9th Malaysia Plan, which is to optimize resources and deliver appropriate services to patients/clients without affecting accessibility to the services. Accordingly, rehabilitation services are now not only available in hospitals, but also in the primary healthcare facilities, where the services provided at selected health clinics throughout the nation. Rehabilitation services at the primary healthcare level are provided by qualified therapist. Starting from year 2002, physiotherapist and occupational therapist were placed in selected health clinics, followed by the placement of speech and language pathologist (speech therapist) in 2017. Rehabilitation services at the primary healthcare level is intended to provide health services encompassing the aspect of promotive, preventive, curative and rehabilitative as early as possible to ensure that the health status of public maintained at the maximal level and quality.
The number of patients and the demand of rehabilitation services in primary health care constantly rising. To date, there are 359 physiotherapists, 256 occupational therapists and 2 speech therapists stationed in 287 health clinics throughout Malaysia, providing rehabilitation services in the 540 health and community clinics including for the outreach services in the institution, Community-Based Rehabilitation Centre (Pusat Pemulihan Dalam Komuniti - PDK), schools and at patient’s home.
206
Figure 130
Number of Patients Attending Rehabilitation in Primary Health Care, Malaysia 2017-2019
Source: Sistem Maklumat Pengurusan Kesihatan: Laporan Bulanan/Tahunan Perkhidmatan Rehabilitasi di Kesihatan Primer,
(Malaysia, Year 2017-2019)
Table 68
Impact Indicator for Rehabilitation Services (Physioterapy and Occupational Therapy) in Primary Health Care
No. Indicator Target Achievement Achievement Achievement (%) Year 2017 Year 2018 Year 2019
Impact Indicators for Physiotherapy Services
1. Percentage of older ≤ 60% 87% 82% 87.89% persons with risk of falling, improved after three (3) months of intervention
Impact Indicator for Occupational Therapy Services
2. Percentage of Older ≥75% 76.4% 78% 85% Persons affected in performing activities of daily living (ADL), improved after three (3) 207
months of intervention
3. Percentage of stroke ≥75% 97.70% 76.10% 87% patients increased ADL function (ADL) after six (6) months of intervention
Source: Borang Pengumpulan Data: Intervensi Warga Emas Berisiko Jatuh (PT/KPI WE 2016) & Borang Pengumpulan Data: Skor Modified Barthel Index (MBI) Untuk Warga Emas (OT/KPI WE 2016)
Table 69
Impact Indicator for Rehabilitation Services (Physioterapy And Occupational Therapy) in Community-Based Rehabilitation Centre (CBR)
Target Achievement Achievement Achievement No. Impact Indicator (%) Year 2017 Year 2018 Year 2019
Impact Indicators for Physiotherapy Services
1. Percentage of CBR staffs ≥60% 89.2% 85% 81% successfully performed
basic physiotherapy excercise techniques to PWDs, in 3 assessment sessions (within 6 months)
2. Number of new students ≥50% 68% 76% 75.3% in CBR assessed and treated by physiotherapist over a period of 3 month
Impact Indicator for Occupational Therapy Services
3. Percentage of PWDs with ≥70% - 75% 81% Learning Diabilities in CBR, aged 5-6 years old, screened for readiness to school, at least once a year
Source: Borang Pengumpulan Data: Semakan Semula Indikator Perkhidmatan Pemulihan Rehabilitasi Di PDK (PT/OT 2018)
208
Occupational Therapy Services in Primary Health Care
In 2019, the total number of patients who attended individual session for occupational therapy services in primary health care were 182,481 while 129,460 had attended group therapy. Of these amounts, 152, 973 were new cases while 158,968 were follow-up cases. Variety of assessment and training modality has been provided for occupational therapy services such as the rehabilitation for activity of daily living, functionality, cognitive and perception, pre-school, wheelchairs, pre-driving, employment, home/workplace, children development, adaptation and modification of equipments/environment, pressure clothing, creative therapy/social/play/recreational activities, relaxation therapy, sensory therapy, splinting and others.
The programmes carried out are as follows; Outpatient Program (23 per cent); Child Health (16 per cent); Diabetes (16 per cent); Children with Special Needs (10 per cent); Mental Health (5 per cent); Elderly Health (5 per cent); Community-Based Rehabilitation (4 per cent); Learning difficulties (3 per cent); Health Promotion/ Camp activities (3 per cent); Psychosocial Rehabilitation, School Programme, Domiciliary Health Care Services (each 1 per cent); and other programs such as Antenatal and Obesity, Obesity, Hypertension, Occupational Health & Safety, Adolescents Health, Supported Employment Rehabilitation, Quit Smoking Programs and Visual Rehabilitation.
Figure 131
Number of Patients Given Physiotherapy Services in Primary Health Care, Malaysia 2019
Source: Sistem Maklumat Pengurusan Kesihatan : Laporan Bulanan/Tahunan Perkhidmatan Pemulihan Carakerja di Kesihatan Primer,
(Malaysia, Year 2019)
209
Figure 132
Number of Patient Receiving Occupational Therapy in Primary Health Care,
Based on Modalities (Malaysia, Year 2019)
Source: Sistem Maklumat Pengurusan Kesihatan: Laporan Bulanan/Tahunan Perkhidmatan Pemulihan Carakerja di Kesihatan Primer, (Malaysia, Year 2019)
210
Figure 134
Number of Attendance to Occupational Therapy Services in Primary Health Care, Based on Programmes (Malaysia, Tahun 2019)
Source: Sistem Maklumat Pengurusan Kesihatan: Laporan Bulanan/Tahunan Perkhidmatan Pemulihan Carakerja di Kesihatan Primer,
(Malaysia, Year 2019)
Physiotherapy Services in Primary Health Care
In 2019, the number of physiotherapy outpatient cases registered for individual session were 373,786, while 343,583 has enrolled in the group session. Of the total, 336,183 were new cases while 397,684 were follow-up case.
Various modalities in physiotherapy services involving treatments, assessments and exercises provided in primary health care, namely electrotherapy treatment such as hotpack, wax bath and cyrotherapy, pain management therapy, therapeutic exercise therapy involving various techniques and exercise methods of recovery, chest physiotherapy, manipulative therapy that require soft tissue manipulation
211
technique, myofascial release techniques with acupressure, ambulation therapy, gait therapy, vestibular therapy among others. Physiotherapy services in primary health care were also being provided through workout aid and exercise tools such as using Continuous Passive Movement (CPM), Cervical and Lumbar Traction Machines and some other tools.
Based on the number of rehabilitation program that has been conducted in primary health care, outpatient treatment programme was the most frequently conducted (53 per cent). This followed by the Elderly Health Programme (17 per cent), Non-Communicable Disease (NCD) program for Diabetes Melitus and Obesity (each 14 per cent), Community-Based Rehabilitation Centre (11 per cent), Antenatal/Posnatal Program (6 per cent), Domicilliary Health Care and Adult Health (each 6 per cent); Occupational Health Safety and NCD Hypertension (each 4 per cent), Children with Special Needs and Health Camp (each 3 per cent), Home Visit and Outreach Program (each 2 per cent), Child Health and Adolescents Health (each 1 per cent) and other rehabilitative programs are 3 per cent.
Figure 135
Number of Patient Receiving Outpatient/Curative Intervention
for Physiotherapy Services in Primary Health Care, Malaysia 2017-2019
Source: Sistem Maklumat Pengurusan Kesihatan: Laporan Bulanan/Tahunan Perkhidmatan Fisioterapi di Kesihatan Primer,
(Malaysia, Year 2017-2019)
212
Figure 136
Number of Patients Receiving Physiotherapy Services in Primary Health Care Based on Program, Malaysia 2019
Source: Sistem Maklumat Pengurusan Kesihatan : Laporan Bulanan/Tahunan Perkhidmatan Fisioterapi di Kesihatan Primer,
(Malaysia, Year 2019) 213
Figure 137
Number of Program Conducted by Physiotherapist in Primary Health, Malaysia 2017-2019
Source: Sistem Maklumat Pengurusan Kesihatan: Laporan Bulanan/Tahunan Perkhidmatan Fisioterapi di Kesihatan Primer
(Malaysia, Year 2017-2019)
214
Figure 138
Number of Patients Given Physiotherapy Intervention in Primary Health Care Based on Program, Malaysia 2017-2019
Source: Sistem Maklumat Pengurusan Kesihatan : Laporan Bulanan/Tahunan Perkhidmatan Fisioterapi di Kesihatan Primer, (Malaysia, Year 2017-2019)
215
Figure 139 Number of Electrotherapeutic Modalities Conducted by Physiotherapist in Primary Health Care, Malaysia 2019
Source: Sistem Maklumat Pengurusan Kesihatan: Laporan Bulanan/Tahunan Perkhidmatan Fisioterapi di Kesihatan Primer, (Malaysia, Year 2019)
216
Figure 140
Number of General Exercise Therapy Modalities Conducted by Physiotherapist in Primary Health Care, Malaysia 2019
Source: Sistem Maklumat Pengurusan Kesihatan: Laporan Bulanan/Tahunan Perkhidmatan Fisioterapi di Kesihatan Primer,
(Malaysia, Year 2019)
217
Figure 141
Number of Special Intervention Therapy Modalities Conducted by Physiotherapist in Primary Health Care, Malaysia 2019
Source: Sistem Maklumat Pengurusan Kesihatan: Laporan Bulanan/Tahunan Perkhidmatan Fisioterapi di Kesihatan Primer,
(Malaysia, Year 2019)
218
Figure 142
Number of Special Intervention Therapy Modalities Conducted
by Physiotherapist in Primary Health Care, Malaysia 2019
Source: Sistem Maklumat Pengurusan Kesihatan: Laporan Bulanan/Tahunan Perkhidmatan Fisioterapi di Kesihatan Primer
(Malaysia, Year 2019)
219
Figure 143
Number of Chest Physiotherapy Modalities Conducted
by Physiotherapist in Primary Health Care, Malaysia 2019
Sour ce: Sistem Maklumat Pengurusan Kesihatan: Laporan Bulanan/Tahunan Perkhidmatan Fisioterapi di Kesihatan Primer,
(Malaysia, Year 2019)
Speech and Language Therapy Services in Primary Health Care
Speech and Language Therapy Services is one of the scope of rehabilitation services in primary health care, initiated in Health Clinic Cheras, Kuala Lumpur and Health Clinic Bandar Botanic Klang, Selangor starting in 2017. Speech and Language Therapist are responsible for providing this service and to date, there is only one therapist in each mentioned health clinic. Apart from working in health clinic, they also provide services in other health clinics in their operational area, as well as participating in outreach services. Their scope of work has broadened out to conducting assessment for speech problems, conducting early intervention for speech and language, provide rehabilitation therapies and awareness programs.
Services provided are for all ages, including services to children with delayed speech development, adults and elderly with stroke, school students with learning disabilities and much more. The scope of services is not only concentrated in the health clinic, but also extended to the community through outreach programs in home, school and government institutions such as the Community-Based Rehabilitation Center (CBR). 220
Table 70
Number of Patient Given Speech and Language Therapy
in Primary Health Care, Malaysia 2018-2019
Health Clinic Number of Number of Patient in Total Community Out-Patient (CBR/School/
Health Camp)
2018 2019 2018 2019 2018 2019
Klinik Kesihatan Cheras 514 513 370 192 884 705
Klinik Kesihatan Bandar 1,071 1,153 30 115 1,101 1,268 Botanik
Source: Reten Perkhidmatan Rehabilitasi Pertuturan di Kesihatan Primer (Malaysia, Tahun 2018-2018)
13.6 Data on Disability: National Health And Morbidity Survey (NHMS)
WHO Global Disability Action Plan 2014-2021 emphasizes on strengthening of relevant data collection on disability, reinforced on research on disability and various services related to disability.
In 2015, MOH has conducted a survey to identify the magnitude of the adult population in Malaysia, through National Health and Morbidity Survey. The prevalence data obtained from the survey are comprehensive and can be compared with other countries. The finding shows that the prevalence of disability among adult in Malaysia was 11.8 per cent (95 per cent CI: 11.15, 12.53). The prevalence of adult with disability contracting with non-communicable disease increased by two folds as compared to the general population in Malaysia.
As a measure to strengthen the existing data obtained from the survey in 2015, another survey has been conducted in year 2019. The National Health and Morbidity Survey 2019 on disability model was conducted to obtain the prevalence of disabilities among children and adults population in Malaysia. A list of validated question from WHO: Washington Group on Disability (WG) was used as survey tools, including several questionnaires on the usage of assistive devices among person with disabilities. Data on usage of assistive devices is one of the indicators in universal health coverage (UHC) monitored by WHO.
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NHMS 2019 data shows that the prevalence of disability among adult population in Malaysia is 11.1 per cent (95 per cent CI: 10.10, 12.21) and in children as much as 4.7 per cent (95 per cent CI: 3.91, 5.71). Data on the prevalence of assistive devices usage among adult population in Malaysia is 76.6 per cent (95 per cent CI: 74.63, 78.45).
14 ELDERLY HEALTHCARE SERVICES
14.1 Introduction
The Ministry of Health Malaysia has introduced the elderly healthcare services for elderly since 1996 as one of the programs in the Expanded Scope of Family Health services. The objective of the services is to ensure elderly achieve the optimal level of health through its holistic and comprehensive healthcare services.
The implementation of elderly healthcare services programme is based on The National Healthcare Policy for the Elderly, which emphasizes the efforts towards healthy ageing by empowering the elderly, family and community with knowledge; together with supportive environment to encourage independent life (Ageing in Place). These services encourage elderly active participation in health promotional activities and life course disease prevention. Other than improving the health status of the elderly, these services provide friendly, equitable, culturally accepted, non-gender discriminating, seamless and comprehensive healthcare.
The ministry upholds the World Health Organization’s active and healthy ageing policy for the elderly at all levels comprising the primary, secondary, tertiary healthcare services and community based care. The Healthy Ageing concept outlines the framework and public health approach in the elderly healthcare targeting the three (3) groups of elderly, namely for the:
• elderly with physically and mentally active and independent elderly to achieve an optimal level of functional ability to continue a healthy living;
• elderly with functional problems to maintain optimal health
• elderly who are bed-ridden and fully dependent on others to maintain their dignity.
Various elderly healthcare services are provided in health clinics (Klinik Kesihatan)which includes health promotional activities, health screening and assessment, medical examination, consultation,
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rehabilitation services, as well as recreational, social, and welfare activities through Kelab Warga Emas in health clinics.
14.2 Elderly Health Care Programme Achievements
In Malaysia, those aged 60 years and above are defined as elderly. Our nation is expected to be an aged nation in 2030 when the number of elderly comprises 15% of the total population.
Registration and health screening of elderly
As of December 2019, a total of 2,832,780 (83.1 per cent) elderly have registered in primary healthcare facilities. The target is to reach 85 per cent at the end of 2025.
Findings from National Health and Morbidity Survey 2018: Elderly Health (NHMS 2018) shows that the prevalence of Diabetes Mellitus, Hypertension and Hypercholesterolemia was 27.7 per cent, 51.1 per cent and 41.8 per cent respectively. Prevalence of probable Dementia was 8.5 per cent and prevalence of depressive symptom was 11.2 per cent.
Hence, the focus on health screening among elderly is crucial in identifying the risk factors as early as possible. A total of 6.2 per cent from the elderly population have been screened using the Borang Saringan Status Kesihatan Warga Emas (BSSK). Figure 144 shows the total number of attendances of elderly clients to health clinics while Figure 145 shows the registration and health screening of elderly conducted at the health clinics from the year 2015 until 2019, as a cumulative figure. The top five (5) main morbidities detected among elderly receiving treatment at primary healthcare services are hypertension, diabetes mellitus, joint problems, respiratory problems, and visual defect (Figure 146). This trend has been similar for the past 5 years , which sees the shift from age related condition to lifestyle associated diseases.
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Figure 144
Attendance of Elderly Clients to Klinik Kesihatan, 2015-2019
Year
Source: Reten PKWE 201A, 2015-2019, Family Health Development Division, MOH
Figure 145
Registration of Elderly in Health Clinics (Cumulative)
and Elderly Health Screening, 2015 to 2019
Year
Source: Reten PKWE 101 pind.1/2013, 2015-2019, Family Health Development Division, MOH
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Figure 146
Morbidity Trend among Elderly, Detected in Health Clinics, 2015-2019
Year
Source: Reten WE 1/2015, 2015-2019 Family Health Development Division, MOH
Health Advocacy for Government Pensioners
Government pensioners are our nation’s assets who deserve our attention and appreciation for their contributions to the country. An initiative, led by the Public Service Department, translates the government's effort in providing a holistic service and care to government pensioners into action. One of the core services under this initiative is the health advocacy, which is being entrusted to the Ministry of Health Malaysia. Government pensioners are given the privilege of utilizing the fast track (R-Lane) and getting the health screening done at health clinics. In 2019, 17.3 per cent of R-Lane users were government pensioners while 9.2 per cent of government pensioners had undergone health screening at the health clinics (Figure 147).
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Figure 147
Trends of Government Pensioners Utilizing the R-Lane and Percentage of Government Pensioners Undergone Health Screening, 2015-2019
Year
Source: Reten NBOS 10, 2015-2019, Family Health Development Division, MOH
Outreach Programme in the Community
The outreach programme was introduced to provide holistic healthcare services to the elderly at institutions and bedridden elderly at home. The services is in tandem with public health response to the needs of older people who have, or are at high risk of significant losses in capacity with the provision of long-term care. A total of 8,992 (95 per cent) of elderly in institution and 1,094 (54.2 per cent) of bed- ridden elderly has undergone a health screening and appropriate treatment have been rendered to them. Figure 148 shows the percentage of health screening and treatment given to the elderly in institutions and bedridden elderly at home from 2015 to 2019.
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Figure 148
Trends of Health Screening and Treatment for the Elderly in Institutions;
and Bedridden Elderly at Home, 2015-2019
Source: Reten NBOS 7, 2015-2019, Family Health Development Division, MOH
1.2.4 Rehabilitation Services
Rehabilitation services (Physiotherapy and occupational therapy) is one of the services provided in the elderly healthcare programme by the Ministry of Health. The services is in-line with public health interventions targeting the elderly with declining capacities in which minimizing the impact of these conditions on overall capacity to help stop, slow or reverse declines in capacity.
Findings from National Health and Morbidity Survey 2018: Elderly Health, showed that 17 per cent of our elderly had functional limitation in performing Activities of Daily Living (ADL), while 41.9 per cent of elderly population are dependent in term of Instrumented Activity of Daily Living (IADL). The performance indicator for these services was monitored since 2017. In 2019, among the elderly screened for risk of fall, 89.0 per cent of them had an improvement after the 3 months intervention period. While 85.1 per cent of elderly clients referred for occupational therapy intervention had an increase of the Modified Barthel’s Index (MBI) scoring within 3 months of intervention.
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Kelab Warga Emas (Senior Citizen Club at Health Clinics)
Kelab Warga Emas is an initiative by Ministry of Health to encourage community participation and strengthening the non-governmental organizations (NGO) engagement while identifying the roles and responsibilities of the community in the elderly health care. It is a platform for elderly to carry out social, religious and spiritual activities with other elderly within the community towards encouraging healthy and active ageing. As of December 2019, there are 284 Kelab Warga Emas established throughout Malaysia, which operates under their respective health clinics. Figure 6 shows the number of Kelab Warga Emas for 2015 until 2019. The target is to set up at least one new Kelab Warga Emas per year in every district.
Figure 149
Number of Kelab Warga Emas, 2015-2019
eyEARar Sumber: Reten PKWE 1/2012, BPKK, KKM (2015-2019)
14.3 Elderly Healthcare Training
The development of human resource must be in tandem with the rapid increase of the aged population. There is a great need in training of healthcare providers, both formal and informal at all levels for an optimal elderly healthcare delivery. Cumulatively, until December 2019, training on elderly healthcare has been provided to 38,533 healthcare personnel, and 37,870 care givers respectively (Figure 150).
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Figure 150
Numbers of Healthcare Personnel and Carers
Been Trained on Elderly Healthcare, 2015-2019
Year
Source: Reten PKWE 1/2012, 2014-2018, BPKK, KKM (2014-2018)
14.4 Main Focus in 2019
Shifting Task of Community Nurses (Jururawat Masyarakat) in Elderly Healthcare Services
Rural clinics (Klinik Desa) provides maternal and child health services, which is delivered by trained community nurses. However, the decline in total fertility rate results in low attendances and this leads to fewer antenatal cases to be handled by the community nurses. Rural clinics especially those in the FELDA settlement areas, received less than fifteen (15) clients per day. Hence, the need arises to expand the scope of function of community nurse in rural clinic to deliver healthcare for the elderly while. Therefore, this new initiative has been carried out by Ministry of Health by identifying all the rural clinics, which has two (2) community nurses and attended by less than fifteen (15) clients a day. The objectives of this initiative are as follows:
i. To optimize the existing resources by expanding the scope of functions and shifting task of Community Nurse in Rural Clinics. ii. To improve the health status and functional capability of older people in the community in line with the public health framework of healthy aging.
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iii. To improve the health care delivery services to the elderly population using the Community Based Primary Healthcare approach. iv. To Increase the knowledge and skills of healthcare professionals in dealing with health care for the elderly.
Table 71 shows the distribution of rural clinics in Malaysia. In 2018, there were a total of 1,792 rural clinics and out of them 789 had the attendances of less than 15 clients per day, which represents 43.9 per cent of the total rural clinics in Malaysia.
Table 71
Distribution Rural Clinic with the Attendance of
Less Than 15 Clients Per Day, Malaysia 2017-2018
No State 2017 2018 No of Rural Clinics Total % of Rural No of Rural Total % of Rural Attendances Clinics Clinics Clinics < 15 Day Attendances Attendance Attendances < 15 Day s < 15 Day < 15 Day 1 Perlis 5 30 16.7% 8 30 26.7% 2 Kedah 34 218 15.6% 36 218 16.5% 3 P. Pinang 7 59 11.9% 9 59 15.3% 4 Perak 160 233 68.7% 164 231 71.0% 5 Selangor 26 116 22.4% 26 114 22.8% 6 N.Sembilan 61 98 62.2% 62 96 64.6% 7 Melaka 23 59 39.0% 22 60 36.7% 8 Johor 148 261 56.7% 153 261 58.6% 9 Pahang 124 239 51.9% 127 239 53.1% 10 Terengganu 34 128 26.6% 33 128 25.8% 11 Kelantan 63 176 35.8% 69 175 39.4% 12 Sabah 79 168 47.0% 72 166 43.4% 13 Sarawak 4 7 57.1% 4 5 80.0% 14 Labuan 1 10 10.0% 1 10 10.0% Total 769 1802 42.7% 786 1792 43.9%
In July 2019, there were a total of 126 rural clinics involved in this initiative, 72 being in Perak while 54 in Pahang respectively. A total of 1,685 elderly were registered and 1,956 were screened for risk factors 230
using the designated checklist. 1,160 of the elderly were detected to have some form of risk factors such as overweight, abnormal blood pressure reading and glucose level. Community nurses subjected them to early intervention before referring them to the health clinics. The elderly were given health education on nutrition, management of drugs, promotion of physical activity and tips on fall prevention. In 2020, this initiative will be expanded to other states in Malaysia involving another 663 rural clinics. Table 72 shows the achievement of this initiative in Perak and Pahang in 2019.
Table 72
Achievement of Initiatives in Pahang and Perak, 2019
Achievement Indicator Target Perak Pahang
1. Total of rural clinics The rural clinics which 72 54 fulfils the criteria
2. Percentage of elderly registered 85 % in 2025 1184 / 13117 501 / 5532 with rural clinics [ 9.0 % ] [ 9.1 % ]
3. Percentage of elderly screened 50 % from elderly 1320 / 13117 636 / 5532 using the checklist population at operational area [ 10.1 % ] [ 11.5 % ]
4.Percentage of elderly having health 25 % from elderly 750 / 1320 410 / 636 risk populati on at operational area [ 56.8 % ] [ 64.5 % ]
5. Percentage of elderly with risk 100 % from elderly 750 / 750 348 / 410 factor, receiving early interventions population at operational area [ 100 % ] [ 84.9 % ]
Development of the National Dementia Action Plan 2020-2030
The World Health Organization (WHO) estimates the prevalence of dementia to be between 5 per cent to 8 per cent among the elderly population. In Malaysia, the NHMS 2018: Elderly Health Survey showed the overall prevalence of probable dementia was 8.5 per cent among elderly aged 60 years and above. Therefore, there is an urgent need for us to develop a dementia action plan as a form of preparation to face the increasing number of elderly diagnosed with Dementia. Currently, the draft is being prepared with the input from all the experts and it is expected to be completed soon.
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CONTRIBUTORS PRIMARY MEDICAL CARE SECTOR PRIMARY HEALTH CARE INFORMATICS SECTOR Dr Fatanah bt Ismail Dr Fairus Zana Bt Mohd Rathi Public Health Physician Public Health Physician Office No :0388832169 Office No :0388832167 Email : [email protected] Email: [email protected]
QUALITY AND INNOVATION SECTOR PRIMARY HEALTH FACILITY INFRASTRUCTURE DEVELOPMENT SECTOR Dr Noraini bt Mohd Yusof Public Health Physician Dr Rohana bt Ismail Office No :0388832158 Public Health Physician Email : [email protected] Office No :0388833911 Email : [email protected] PRIMARY EMERGENCY CARE SECTOR CLINICAL AND TECHNICAL SUPPORT SERVICES SECTOR Dr Rachel Koshy Public Health Physician Dr Mohd Safiee bin Ismail Office No :0388832171 Public Health Physician Email: [email protected] Office No:0388832141 Email: [email protected]
PRIMARY POLICY DEVELOPMENT SECTOR MATERNAL HEALTH SECTOR Dr Noridah Bt Saleh Dr Majdah Bt Mohamed Public Health Physician Public Health Physician Office No:0388832068 Office No: 0388834046 Email : [email protected] Email: [email protected]
CHILD HEALTH SECTOR SCHOOL HEALTH SECTOR Dr Aminah Bee bt Mohd Kassim Dr Saidatul Norbaya bt Buang Public Health Physician Consultant Public Health Physician Office No: 0388834003 Office No: 0388834002 Email: [email protected] Email: [email protected]
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ADOLESCENT HEALTH SECTOR ADULT HEALTH SECTOR Dr Nik Rubiah bt Nik Abdul Rashid Dr Zakiah bt Mohd Said Public Health Physician Consultant Public Health Physician Office No: 0388834047 Office No: 0388834048 Email: [email protected] Email: [email protected]
ELDERLY HEALTH SECTOR PEOPLE WITH DISABILITY Dr Noraliza bt Noordin Merican Dr Salimah bt Hj Othman Public Health Physician Public Health Physician Office No: 0388834045 Office No: 0388834041 Email: [email protected] Email: [email protected]
COORDINATOR
Dr Aizuniza Abdullah Dr Amal bt Shamsudin Public Health Physician Senior Principal Assistant Director Office No: 0388834044 Office No: 0388834378 Email: [email protected] Email: [email protected]
Dr Noor Azura bt Ismail Senior Principal Assistant Director Office No: 0388832337 Email: [email protected]
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