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Rural health care in Malaysia

Article in Australian Journal of Rural Health · May 2002

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Aust. J. Rural Health (2002) 10, 99–103

Review Article
2002
Blackwell
Oxford,
The
AJR
1038-5282
AUSTRALIAN
456
10
RURAL
10.1046[sol
Australian
Blackwell
UK
HEALTH
Science,
]j.1038-5282.2002.00456.x
Journal
JOURNAL
Science
Ltd
CAREofAsia
Rural
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MALAYSIA:
RURAL
Health
Ltd HEALTH
K. M. ARIFF and C. L. TENG Review
BEES SGML
Article

RURAL HEALTH CARE IN MALAYSIA

Kamil Mohamed Ariff1 and Teng Cheong Lieng2
1Klinik Kamil Ariff, Perlis and 2International Medical University, Negeri Sembilan Darul Khusus,
Malaysia

ABSTRACT: Malaysia has a population of 21.2 million of which 44% resides in rural areas. A major priority of
healthcare providers has been the enhancement of health of ‘disadvantaged’ rural communities particularly the rural
poor, women, infants, children and the disabled. The Ministry of Health is the main healthcare provider for rural
communities with general practitioners playing a complimentary role. With an extensive network of rural health
clinics, rural residents today have access to modern healthcare with adequate referral facilities. Mobile teams, the flying
doctor service and village health promoters provide healthcare to remote areas. The improvement in health status of
the rural population using universal health status indicators has been remarkable. However, differentials in health
status continue to exist between urban and rural populations. Malaysia’s telemedicine project is seen as a means of
achieving health for all rural people.
KEY WORDS: healthcare, infrastructure, Malaysia, morbidity, rural.

INTRODUCTION the health needs of the employees. Rural residents depended

The Malaysian population is a heterogeneous, multi-ethnic
group consisting of Malays (51%), Chinese (27%), other
Bumiputras (indigenous people) (11%), Indians (8%) and
other ethnic groups (3%). The 1996 population estimate
was 21.2 million of which 44% or 9.3 million reside in
rural areas.1 The majority of the rural population (75.8%)
are Malays and other Bumiputras.1
Historical perspective
When Malaysia gained independence from Britain in
1957, the healthcare system catered predominantly to the
needs of urban communities.2 Each of the 11 States had
a State hospital run by medical officers, paramedics and
nurses while specialist services were scarce. Rural health
services were largely non-existent and, if available, were
based in health centres located in small country towns. Many
of the large rubber estates owned by British companies
had set up estate clinics managed by paramedics to serve
Correspondence: Kamil Mohamed Ariff, Klinik Kamil Ariff,
15, Jalan Syed Hussain, 02600 Arau, Perlis, Malaysia. Email:
fm003@pc.jaring.my
Accepted for publication January 2002.
mainly on traditional healers, Chinese medicine shops
and traditional midwives for their healthcare needs. In
1963 the States of Sabah and Sarawak (both located in
the island of Borneo) opted to join Malaysia. The entry of
Sabah and Sarawak, known for their vast areas of tropical
rainforests, resulted in an enormous demand for healthcare
to their rural and remote communities. These communities
had diverse cultural and sociodemographic characteris-
tics, low educational levels and a large aboriginal popula-
tion residing in geographically inaccessible areas.
Development of the rural health service
Well before the Alma Ata Declaration in 1978, Malaysia
had embarked on initiatives to enhance the health status
of the disadvantaged sections of the population, particu-
larly those in the rural areas. Beginning with the First
Malaysia Plan in 1966,3 healthcare infrastructure in rural
areas was built in tandem with other socioeconomic
development such as roads, water supply, electricity and
land schemes. The important determinants in planning
rural healthcare were the diversity of the rural population
in terms of cultural characteristics, socioeconomic status,
their special health needs, belief systems and community
preferences. The emphasis has always been on the equity
and quality of healthcare delivered.
100 AUSTRALIAN JOURNAL OF RURAL HEALTH

By the early 1970s, rural healthcare was delivered

through a three-tier system consisting of a main health
centre (with a medical officer, a dentist, nurses, midwives,
medical assistants and public health team), a health
sub-centre (with medical assistants, nurses and midwives)
and midwife clinics.2 In 1973, a two-tier system was
initiated when the health sub-centres were upgraded to
the status of main health centres (currently called klinik
kesihatan or health clinic) to enhance the quality and
scope of healthcare (Fig. 1). The midwife clinics were
gradually replaced by klinik desa (community clinics)
with a trained and qualified jururawat masyarakat
(community nurse).
Each community clinic provides healthcare to a popu-
lation of 4000 while the rural health unit (one health
clinic with four community clinics) caters to a population
of 20 000. The community nurse handles the community
clinic single-handedly and consults the doctor in the
health clinic where necessary. Her focus is maternal and
child health, particularly antenatal care, postnatal care,
contraception, immunisation and developmental assess-
ment. Home visit is part of the routine of the community
nurse where most postnatal care is provided as well as
detection of neonatal jaundice.
At present, most of the health clinics are managed by
the Medical and Health Officer (MHO) who accepts
referral from the medical assistants, nurses and midwives.
The MHO is also expected to oversee the work of the
public health team (e.g. food inspection, vector control,
surveillance of infectious diseases). Some of the larger
health clinics are currently being managed by a family
medicine specialist (who has postgraduate training in
family medicine).4,5 Many of these health clinics are now
equipped with laboratory, diagnostic imaging facilities
(X-ray, ultrasound) and provide a much wider range of
services (e.g. geriatric programs and delivery services).
Thus, the elements of primary healthcare are the main
focus of the rural health service and include: health
education; nutrition; maternal and child health; immun-
isation; family planning; prevention and control of
endemic diseases; treatment of common illness with ade-
quate supply of essential drugs; environmental sanitation;
and dental health. All these services are financed by
taxes and other public revenues; the patients are charged
one Malaysian Ringgit (about US$0.25) per visit inclusive
FIGURE 1: Rural health unit (two-tier and three-tier systems).
of medication.5
By the year 1997, the ratio of health clinics to popu-
lation was 1:28 000. The current population coverage of rural health clinics, safe delivery (conducted by trained
primary healthcare services is about 95% in west personnel) is achieved for > 95% of deliveries. Current
Malaysia (Peninsular Malaysia) and 70% in east Malaysia immunisation coverage rates for most vaccines exceed
(Sabah and Sarawak).6 With a widespread network of 90%.7
RURAL HEALTH CARE IN MALAYSIA: K. M. ARIFF AND C. L. TENG 101

Remote and aboriginal healthcare small country town that provides healthcare to the adja-
cent rural communities. Rural residents travel to seek
The provision of healthcare to rural and remote commun- the services of rural GPs and it is rare for a rural practice
ities in the east Malaysian States of Sabah and Sarawak to be located in an isolated rural or remote community.
has been a major challenge for Malaysian healthcare Like their urban counterparts, rural GPs do not maintain
planners. Sarawak has a population of around 2 million formal organisational links with the government health
living on a vast land area of 125 450 km2 of which about services. They do not differ significantly from their urban
75% is still covered by dense jungle. Over 50% of Sarawak’s counterparts in relation to practice style and procedural
population resides in rural areas with access to a variety work though long practice hours and house calls can take
of traditional healthcare systems. Providing modern up much of their time. Studies on factors that motivate
healthcare to a population that resides in about 4000 Malaysian doctors to enter rural practice are scanty. It is
longhouses and is linked to nearby towns through a net- the author’s view that an important motivating factor to
work of rivers has been an immense task. From the late 1970s enter rural practice is the fact that most towns and cities
and early 1980s, a network of health centres run by para- are saturated with general practices and there are greater
medics and midwives were set up (doctors are still mainly financial rewards in rural practice. Having lived in a rural
based at the hospitals). The health centre provides health- area and familiarity with the local residents may be other
care for an area not exceeding 12 km with a population of motivating factors. Although the Academy of Family
between 1500 and 3000 people.8 Communities living Physicians Malaysia and the local universities provide
within a 4.8 km radius from the centre (‘immediate opera- training for general practice, there is as yet no specific
tional area’) are expected to seek healthcare in the centre training for rural practice.
while those living within a radius of 4.8 –12 km (‘extended
operational area’) are served by village health teams (run Traditional medicine
by nurses and medical assistants using boats; Fig. 2). Traditional healthcare services have existed in Malaysia
The flying doctor service (FDS) is available in the for centuries and comprise a variety of systems, namely
States of Sarawak and Sabah. The FDS in Sarawak was
launched in 1973 to provide healthcare to communities
residing outside the ‘extended operational area’ limits of
the health centre (beyond 12 km).9,10 The FDS currently
uses helicopters to transport medical teams that provide
healthcare to a village once a month. The flying medical
team consists of a doctor, a medical assistant and two
community nurses. Considering the infrequency of the
FDS visits, a system of village health promoters was initi-
ated in 1981. Two volunteers from participating villages
are trained for a period of 3 weeks in first aid and basic
healthcare. Upon completion of training, they are sup-
plied with first aid kits and commonly used medications
to provide and promote healthcare to their village resi-
dents. The system of village health promoters has done
remarkably well and by the end of 2000, there were 2857
village health promoters throughout the State, serving a
total of 262 368 people from 1583 villages.11

ROLE OF GENERAL PRACTITIONERS

4.8 km
The government, through the Ministry of Health and other
agencies, is still the main provider of rural health services 12 km

in Malaysia. During the past three decades, an increasing

12 km
number of doctors have left the government service to
become rural general practitioners. Rural practice in the
Malaysian context refers to a private general practice in a FIGURE 2: Operational area of health clinic in Sarawak.
102
Malay, Chinese, Indian, Thai and aboriginal systems.
Despite the wide availability of modern scientific health-
care services that are accessible to Malaysia’s rural and
remote populations, traditional healthcare services are
still used by Malaysian communities for a variety of
health and psychosocial problems.5 The popularity of the
services of the traditional healer particularly for the treat-
ment of musculoskeletal problems, psychological illness
and illness perceived to be supernatural in origin
(charms, witchcraft, evil spirits) is widely acknowledged
by rural communities and conforms to the author’s (a rural
family physician) personal observation.12,13
Morbidity in rural communities
The rural Malaysian community perceives health as a
feeling of well-being and an ability to participate in social
activities – a feeling of harmony that helps a person
integrate into his or her environment and interact with
community members. It is the author’s view that this notion
of health often leads to asymptomatic health problems
like hypertension, diabetes, hyperlipidemia and anaemia
being left untreated until complications arise.
The National Health and Morbidity Survey (NHMS)
conducted in 1996 that measured both the felt and
expressed needs of the population showed that the rural
population had a higher prevalence of recent illness and
physical disability.14 The percentage of adults with pre-
viously undiagnosed hypertension was higher in rural
localities. Prevalence rates for current smokers and
alcohol drinkers were also significantly higher in the rural
population than in urban areas. Rates for Pap-smear
examination and breast self-examination were lower in
rural populations. Overall, only 26% of Malaysian
women had ever had a Pap-smear done (28.4% for urban
women and 22.8% for rural women). The NHMS also
reported a lower percentage of rural residents had sought
healthcare for their recent illness or injury though they
had felt a need to seek care.
The rapid pace of economic activities, such as,
logging, jungle clearing for construction of highways, hydro-
electric projects and townships has had a negative impact
on the health of the Aboriginal population. Their tradi-
tional lifestyle has been disrupted. Their resettlement to
new areas has contributed to the deterioration of their
physical and emotional health, and adversely affected the
nutritional status of children.15–17 Food taboos, ignorance,
disruption of traditional value systems and lack of access
to the foods that were once available in their traditional
habitats have contributed to their poor nutritional status.
On the other hand, health problems that are associated
with a sedentary lifestyle and overnutrition, such as obesity,
AUSTRALIAN JOURNAL OF RURAL HEALTH
hypercholesterolemia and hypertension have also been
reported.18
Factors such as rural poverty, ignorance, behaviour,
culture and the status of women have adversely influ-
enced the use of rural healthcare despite the govern-
ment’s best efforts to provide access to modern
healthcare. Thus, differentials in health status continue to
exist between urban and rural Malaysian communities.
Diseases such as malaria, tuberculosis, leprosy, mild
and moderate forms of malnutrition, pregnancy-related
problems, obstructive airway disease, injuries and psy-
chiatric illnesses are still issues of concern to rural
healthcare providers.6 Outbreaks of infectious diseases
like typhoid and cholera do occur sporadically. The control
of dengue fever remains a significant problem both in
urban and rural areas.
THE FUTURE
Malaysia has done remarkably well in establishing an
extensive network of rural healthcare services and deliv-
ering cost-effective healthcare as a vital part of the
nation’s socioeconomic development. Any future strat-
egies to enhance rural health should continue to be a
collaborative effort on the part of the Ministry of Health
and other government and non-government agencies. The
relationship of health with every other aspect of rural
life should be the guiding principle with clear strategies
aimed at reducing rural poverty, enhancing literacy,
changing lifestyle and dealing with the social inequalities
that affect the status of rural women.19 Strategies targeted
to improve rural health should be planned with adequate
and active community participation and empowerment to
initiate lifestyle change and discard unhealthy traditional
beliefs and practices. Studies on the Malaysian Aboriginal
population (Orang Asli) have shown that greater commu-
nity participation in efforts to promote immunisation,
family planning and improved nutrition were more likely to
be culturally sensitive and friendly and bring about better
health outcomes.20 ‘The Kuching Statement on the Health
of Indigenous Peoples’ affirmed the need for health pro-
fessionals to receive training in indigenous health issues
and adequately address the health of indigenous women
in particular.21
Plans are being identified to reshape the future of the
Malaysian health system from one that is illness and dis-
ease focused to one that is wellness focused. A telemedi-
cine pilot project in Sarawak was initiated in 1997 to test
the practicality of providing telemedicine (teleconsulta-
tion and teleradiology) by linking six district hospitals
that lacked infrastructural development and specialist
RURAL HEALTH CARE IN MALAYSIA: K. M. ARIFF AND C. L. TENG
services via Internet to the Sarawak General Hospital.
Within a 2-week period, it was clear that the Internet was
a viable and cost-effective medium with significant
savings on travelling costs for patients referred to hospitals,
telephone charges, travelling time for specialists and a
viable technology for continuing medical education.22
Plans are being formulated to extend telemedicine ser-
vices to all health clinics. The telemedicine project in
Malaysia is seen as an important means of achieving
health for all rural people.
ACKNOWLEDGEMENTS
The authors wish to thank Associate Professor H. Yadav
from the Department of Social and Preventive Medicine,
University Malaysia and Dr M. K. Rajakumar for their
helpful comments in preparing this article.
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