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Ers in a Rural District of Malaysia and Their Interactions with Public Health Services

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Ers in a Rural District of Malaysia and Their Interactions with Public Health Services Al Junid, Syned Mohamed (1995) The role of private practition- ers in a rural district of Malaysia and their interactions with public health services. Doctoral thesis, London School of Hygiene Tropical Medicine. Downloaded from: http://researchonline.lshtm.ac.uk/682275/ Usage Guidelines Please refer to usage guidelines at http://researchonline.lshtm.ac.uk/policies.html or alterna- tively contact [email protected]. Available under license: Copyright the author THE ROLE OF PRIVATE PRACTITIONERS IN A RURAL DISTRICT OF MALAYSIA AND THEIR INTERACTIONS WITH PUBLIC HEALTH SERVICES. by Syed Mohamed Aijunid MD (Malaysia) MSc (Pubic Health) (Singapore) Thesis submitted to the Faculty of Science of the University of London for the degree of Doctor of Philosophy Health Policy Unit London School of Hygiene and Tropical Medicine September 1995 © ABSTRACT A study was carried out to examine the role of private practitioners in a rural district in Malaysia and to identify the nature of their interactions with public health services. Underlying null hypotheses were that there is no difference in the nature of the services, the characteristics of the health workers or the clientele of public and private sector facilities and that the interactions between both types of providers were mutually beneficial. Five sub-studies were conducted among 15 private clinics and six public health facilities in Kuala Selangor district. Quantitative and qualitative techniques were used and efforts made to triangulate and validate findings. The nature of services in private clinics is influenced by competition with other facilities, the demand for the services by users and the attempt to maximise profits by the providers. Most private clinics offered a wider range of curative services, operated for longer and had more flexible hours than public facilities. However, private practitioners had a limited role in providing preventive services. Private clinics were mostly run by older doctors supported by younger and untrained staff while public facilities were run by younger doctors supported by older and more experienced staff. Users of private facilities were more likely to be non-Malays, of higher socio-economic status, seeking curative care for acute illnesses and financed by third party cover. Users of private facilities were prescribed more drugs and expensive investigations than those using public facilities. Weak andinappropriate policies, lack of incentives, poor inter and intra-agency collaboration and negative attitudes between the providers were among the problems identified in public-private interactions. :i. Malaysian policy makers need to engage in a consultative process in order to define the best mix of regulations, incentives and other methods aimed at improving the services offered by the providers and improving their interactions. ii TABLE OF CONTENTS PAGE ABSTRACT TABLEOF CONTENTS ................. • iii LIST OF TABLES viii LISTOF FIGURES .................. xiii LISTOF BOXES ................... xv GLOSSARYOF TERMS ................. xvi ABBREVIATIONS................... xix ACKNOWLEDGEMENTS • xx CHAPTER I. INTRODUCTION 1.1 Organisation of the thesis ..... 1 1.2 Rationale for the study 1 II. LITERATURE REVIEW 2.1 Introduction ............. 4 2.2 Definition .............. 4 2.3 Debate on public and private health care................. 5 2.4 Significance of private health care in Asian countries .......... 12 2.5 Factors influencing utilisation of healthservice ............ 15 2.5.1 Characteristics of the subjects . 16 2.5.2 Characteristics of the disorder . 2]. 2.5.3 Characteristics of the service . 22 2.6 Interaction between public and private providers 31 2.6.1 Enforcement of regulation 31 2.6.2 Human resources 34 2.6.3 Patient referrals 36 2.6.4 Disease notification ......... 38 2.7 Summary 4]. III. STUDY SETTING 3.]. Malaysia - the country ........42 3.2 Health status ............42 3.3 Health services in Malaysia .....47 iii 3.3.1 Public health services ........47 3.3.2 Private health services .......50 3.4 Health services financing ......52 3.5 Kuala Selangor district .......55 IV. MATERIALS AND METHODS 4.1 Aim 58 4.2 Specific objectives 58 4.3 Methods 58 4.3.1 Preparatory phase 59 4 .3.2 Field work .............. 60 4.3.3 Source of data ............ 62 4.3.4 Data analysis 78 V. SURVEY OF HEALTH FACILITIES 5.1 Results 80 5.1.1 Clinic location 80 5.1.2 Providers 80 5.1.3 Clinic operation 81 5.1.4 Medical equipment and supplies . 90 5.1.5 Medical records 91 5.1.6 Charges 93 5.1.7 Clinic drug lists 94 5.1.8 Spot checks 96 5.1.9 Prospective recording 96 5.2 Summary 103 VI. SURVEY OF HEALTH WORKERS 6.1 Results 104 6.1.1 Socio-demographic characteristics 104 6.1.2 Training ............... 109 6.1.3 Job satisfaction ........... 110 6.1.4 Attitudes towards patients ...... 124 6.2 Summary 129 VII. STUDY OF INTERACTIONS BETWEEN PUBLIC AND PRIVATE SECTOR 7.1 Outline ...............130 7.2 Immunisation returns from PPs . 130 iv 7.2.1 Background 130 7.2.2 Findings from Kuala Selangor District 130 7.3 MOH/MM Hepatitis B immunisation project 133 7.3.1 Background .............. 133 7.3.2 Findings from Kuala Selangor District 137 7.4 Patient referrals 141 7.4.1 Referral centres ........... 141 7.4.2 Types of cases referred 143 7.4.3 Private to public sector referrals 144 7.4.4 Public to private sector referrals 152 7.5 tJtilisation of public ambulance byPPs................ 154 7.5.1 Background .............. 154 7.5.2 Findings from Kuala Selangor District 155 7.6 Medical examinations of foreign workers 158 7.6.1 Background .............. 158 7.6.2 Findings from Kuala Selangor District 160 7.7 Private practice by public doctors 162 7.7.1 Background .............. 162 7.7.2 Findings from Kuala Selangor District 163 7.8 Disease notifications 166 7.8.1 Background .............. 166 7.8.2 Findings from Kuala Selangor District 166 7.9 Summary 171 VIII. USER INTERVIEWS 8.1 Results 174 8.1.1 Respondents 174 8.1.2 Socio-demographic characteristics of users 174 8.1.3 Medical conditions 178 8.1.4 Choice of providers 181 8.1.5 Patient management 183 8.1.6 Multiple logistic regression 191 8.2 Summary 193 V IX. STUDY OF COMMUNITY SATISFACTION 9.1 Results 194 9.1.1 Respondents 194 9.1.2 Choice of health facilities 194 9.1.3 Satisfaction with public and private facilities.............. 195 9.2 Summary 210 X. DISCUSSION 10.1 Limitations of the study ....... 211 10.1.1 External factors ........... 21]. 10.1.2 Internal factors ........... 212 10.2 Triangulation of findings 214 10.3 Explanations and interpretations of findings 216 10.3.1 Nature of services .......... 217 10.3.2 Human resources 228 10.3.3 Clientele of pubic and private facilities.............. 235 10.3.4 Interactions between public and privatesector ............ 242 10.4 Summary 252 XI. POLICY IMPLICATIONS 11.1 Regulation of private practitioners 253 11.2 Mobilising of resources for the health sector 260 11.2.1 Improvement in efficiency 260 11.2.2 New resources for health care . 266 - 11.3 Delivery of health services 269 11.4 Coordination between public and privatesector ............ 270 11.5 Summary 271 XII. CONCLUS ION AND FURTHER RESEARCH 12 .1 Methods ...............273 12.2 Role of private practitioners . 273 vi 12.3 Interactions between private practitioners and public health services...............274 12.4 Further research ...........275 XIII. REFERENCES ..................277 APPENDICES .....................304 vii LIST OF TABLES Page 3.]- Health indicators for Malaysia in 1981 and 1991 44 3.2 Ethnic differentials in selected health indicators for Peninsular Malaysia, 1990 45 3.3 Distribution of manpower and facilities in public and private health sector in Malaysia in 1991 50 3.4 Health sector expenditure in Malaysia, 1983 53 3.5 Socio-economic and health indicators for Kuala Selangor District, 1991 ....... 56 3.6 MOH operating and development allocation for Kuala Selangor District, 1992 ..... 56 5.1 Location of private and public facilities in Kuala Selangor District 80 5.2 Operating hours of public and private facilities 82 5.3 Workload in public and private facilities 82 5.4 Curative and preventive services provided by public and private facilities 85 5.5 Diagnostic services in public and private facilities 88 5.6 Availability of basic equipment and supplies in public and private facilities 91 5.7 Availability of emergency equipment and supplies in public and private facilities 91 5.8 Charges in public and private facilities 94 5.9 Types of drugs available in public and private facilities 95 5.10 Type of care sought by public and private patients by gender 100 5 .11 Referral rates and place of referral in public and private facilities ....... 101 5 . 12 Descriptions of variables used in multiple logistic regressions 102 5 .13 Results of analysis using multiple logistic regression on factors influencing viii the use of private facilities 102 6.]. Gender distribution of public and private sector personnel 105 6.2 Ethnic distribution of public and private sector personnel 105 6.3 Differences in age between public and private sector personnel 106 6.4 University background of public and private sector doctors 107 6.5 Educational level of public and private sector staff 107 6.6 Income distribution among public and private sector doctors 107 6.7 Income distribution among public and private sector staff 108 6.8 Length of service among public and private sector personnel 109 6.9 Attendance of pre-employment training among public and private sector staff . 109 6.10 In-service training attended by public and private sector personnel 110 6 . 11 Proportions of public and private sector personnel who were satisfied with various aspects of their jobs ........... 111 6 . 12 Description of variables used in multiple regression analysis of job satisfaction and attitude scores ...........
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