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Bridging the gap in ageing: Translating policies into practice in Malaysian Primary Care

Bridging the gap in ageing: Translating policies into practice in Malaysian Primary Care Population ageing is poised to become a major challenge to the health system as Malaysia progresses to becoming a developed nation by 2020. This article aims to review the various ageing policy frameworks available globally; compare aged care policies and health services in Malaysia with Australia; and discuss various issues and challenges in translating these policies into practice in the Malaysian primary care system. Fundamental solutions identified to bridge the gap include restructuring of the health care system, development of comprehensive benefit packages for older people under the national health financing scheme, training of the primary care workforce, effective use of electronic medical records and clinical guidelines; and empowering older people and their caregivers with knowledge, skills and positive attitudes to ageing and self care. Ultimately, family medicine specialists must become the agents for change to lead multidisciplinary teams and work with various agencies to ensure that better coordination, continuity and quality of care are eventually delivered to older patients across time and settings. Introduction population in Australia are healthier and better educated Population ageing remains a global phenomenon in this than their Malaysian counterparts. new millennium and is poised to become a major issue in Whilst the definitions of chronological age for the older developing countries. Malaysia, an upper middle income people in Malaysia and Australia are different, compari- country, with a population of 28 million is no exception son can still be made because chronological age is not a [1]. Its ageing population of 60 years and above is rising precise marker for the biological changes which accom- steadily from 5.7% in 1990 to 6.3% in 2000 and is expected pany ageing. The chronological age of 60 years and above to be 9.8% in 2020 [2]. Like other countries, population seems young in the developed world, but for a developing ageing in Malaysia is a result of declining fertility, falling country such as Malaysia where gains in life expectancy mortality rates and improvements in the health system. have not yet matched the developed world, this definition Effective prevention of infectious diseases and better nutri- is more appropriate [7]. Chronological age has little or tion has resulted in more people surviving into old age no importance in the meaning of old age in many parts [3,4]. Life expectancy among Malaysians has also risen to of the developing world [8]. Other socially constructed 71.7 years for men and 76.5 years for women in 2007 [5]. meanings of age may be more significant such as the Despite the improvement in life expectancy; poverty, lack roles assigned to older people. In some cases, it is the loss of roles accompanying physical decline which is sig- of education and poor social support tend to influence the nificant in defining old age. well being of its older population. In comparison to Australia, a developed country with A Malaysian burden of disease study conducted in 2004 22 million population, 13.3% of its populace are aged using disability adjusted life years (DALY) showed that the 65 years and over [6]. Life expectancy for Australian males five leading causes of disease burden were coronary heart is 79 years and for females is 84 years [6]. The older disease, mental illnesses, cerebrovascular disease, road traffic injuries and cancer [9]. This trend is similar to that * Correspondence: ambigga@salam.uitm.edu.my in Australia as the five leading causes of disease burden Discipline of Primary Care Medicine, Faculty of Medicine, Universiti using DALY in 2003 were coronary heart disease, anxiety Teknologi MARA (UiTM), 40450 Shah Alam, Selangor, Malaysia and depression, type 2 diabetes mellitus, cerebrovascular Full list of author information is available at the end of the article © 2011 Ambigga et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Ambigga et al. Asia Pacific Family Medicine 2011, 10:2 Page 2 of 7 http://www.apfmj.com/content/10/1/2 disease and dementia [10]. Hence, Malaysia is at an epide- hence different domains have been chosen by the var- miological transition where non-communicable diseases ious countries. Since there are dramatic variations in are now dominating its burden at a par with those of health status, participation and levels of independence developed countries. This pattern of disease is especially among older people of the same age in different coun- predominant among the older population in both tries, decision-makers need to take this into account countries [10,11]. when designing policies and programmes for their older As Malaysia progresses in its path to becoming a populations. developed nation by 2020, population ageing is inevita- ble and this will generate new challenges in terms of Comparing Aged Care Policies of Malaysia with Australia health and social services [11]. In view of this phenom- In most Asian countries, co-residing with an older rela- enon, this article aims to review the various ageing pol- tive and providing aged care is part of the cultural tradi- icy frameworks available globally; dissect various issues, tion. Policy makers in Asia aim at maintaining these policies and health services pertaining to the older cultural norms and values rather than developing poten- population in Malaysia; discuss the challenges of trans- tially expensive formal aged care programs and facilities. lating these policies into practice in the Malaysian pri- These policies focus on the older person remaining inte- mary care system; and consider fundamental solutions grated in society and being included in the formulation needed to address improving the health of older people and implementation of policies that affect their wellbeing in Malaysia. [3]. In Malaysia, a multi-sectoral and multidisciplinary approach was required to set up these policies and they Ageing policy frameworks available globally emphasized the sharing of responsibility between govern- Issues involving the ageing society in each country are ment, private sectors, non-government organisations, unique, resulting in the adoption of various frameworks community and the older people themselves in order to for ageing throughout the world. A number of these are meet their needs [18]. summarised in Table 1. There have been a number of national policies put in These frameworks cover various domains which place for older people in Malaysia. The first policy was include longevity, physical health, activities of daily liv- the National Social Welfare Policy (1990).This policy ing, autonomy, psychological well being, social relation- addressed the need for the care of older persons by ships, work participation, financial security, housing, families and communities [18].This was later strength- transport, safety, leisure activities, quality of life, age dis- ened with the National Policy for the Elderly (1995) crimination and attitudes [12-17]. These frameworks aimed at “creating a society of elderly people who are contented and possess a high sense of self worth and and their attendant policies help guide the development of relevant programmes, facilities and services around dignity, by optimising their self potential and ensuring them. that they enjoy every opportunity as well as care and These various policy frameworks for the different protection from members of their family, society and countries are designed based on the rights, needs, pre- nation” [7]. The National Council of Senior Citizen’s ferences and capacities of older people in each country Organization Malaysia (NACSOM), the Gerontological Table 1 Various ageing policy frameworks available globally Policy Definitions Countries frameworks Adopting Active Ageing Continuing participation in social, economic, cultural, spiritual and civic affairs by older persons and not United Kingdom (WHO) just being physically active or mere participation in the labour force [12]. and Europe Active Ageing Optimizing opportunities for physical, social, mental well being throughout life, in order to extend Malaysia (Adapted) healthy life expectancy, productivity and good quality of life as people age [13]. Healthy Ageing All Australians have the opportunity to maximise their physical, social and mental health throughout life. Australia Population health strategies promote and support healthy ageing across the lifespan. Information, research and health care infrastructure is available to support the healthy ageing of the Australian population [14]. Successful Multiple dimensions of functioning and wellness are measured and these include cognitive and affective Singapore Ageing status, overall physical health, social functionally and life engagement including life satisfaction. These will form the salient determinants of successful ageing [15]. Healthy Ageing A lifelong process of optimising opportunities for improving and preserving health and physical, social Canada and mental wellness, independence, quality of life and enhancing successful life-course transitions [16]. Positive Ageing Shine a positive light on ageing and older persons by recognizing their potential skills and ability rather New Zealand than their age [17]. Ambigga et al. Asia Pacific Family Medicine 2011, 10:2 Page 3 of 7 http://www.apfmj.com/content/10/1/2 Association of Malaysia (GEM) and others provide the There is also an increasing pattern of orthopaedic dis- impetus in developing these policies and services for eases in the ageing population [28] and functional older people in Malaysia [4]. impairment was found to be common among older peo- In contrast, ageing policy in Australia reflects different ple in the community [29]. Based on the NHMS III cultural norms and focuses on consolidating and progres- report, the greatest impact of functional independence sing reforms to ensure choice and access to quality aged in the elderly is on mobility, self care, housework and care services while relying on the role of informal support access to public places [20]. The survey also reported a higher prevalence of chronic pain in the elderly which [19]. In Australia, the focus is on ageing in place through interfered with their daily activities [20]. community support and services. Nevertheless this is changing towards person-centred approaches that pro- Another study also found that erectile dysfunction is mote independence. prevalent and this usually co-exists with type 2 diabetes Societal pressures and expectations are changing in and depression [30]. Urinary incontinence is an impor- Malaysia with an increasing number of older people tant and common problem and can lead to poor quality residing in the cities following the rural-urban migration; of life without timely management [31]. the changing pattern of families into nuclear types; and Psychological health problems are also prevalent among the changing role of women from caregivers to wage older people in Malaysia [32]. A community survey con- earners to support their families. Therefore, it is timely ducted in an urban area found that the prevalence of for Malaysia to revise its policies and be prepared to depression in the elderly was 6.3% [33]. The prevalence of invest morein qualityagedcareservicesinresponseto depression among the elders attending a health clinic was these changes in cultural norms and values. reported to be even higher at 18% [34]. In this age group, depression often co-exists with other chronic illnesses Health issues involving the ageing society in Malaysia [35]. This condition is common in primary care and there- Health issues pertaining to ageing are unique for each fore providers should play a key role in the detection and society. In order to gain a deeper understanding of the management [36]. health issues in the Malaysian ageing population, we The other non-health factors which should be conducted a comprehensive literature review of the addressed in Malaysia includes work, retirement and health and medical research involving Malaysian elders income, housing and institutionalisation, family and the using electronic databases including Medline, Google community, leisure and personal characteristics which Scholar, PubMed, Scopus and Web of Science. Based on can influence the quality of life of this vulnerable group [3]. These however, are beyond the scope of this paper. the published literature, ageing health issues in Malaysia In summary, published evidence has repeatedly high- can be summarised into 3 main domains - physical health, psychosocial health and nutritional problems. lighted that older Malaysian population suffers from mul- According to the Third National Health and Morbid- tiple and complex health needs which require holistic itySurvey(NHMSIII),chronic illnesses were reported and comprehensive long term care in the community. to be most prevalent (48.8%) amongst the 60 and above Despite this fact, Malaysia struggles to translate its poli- age group [20]. Malaysian elders are commonly affected cies into practice. A closer scrutiny of how the Malaysian by multiple chronic non-communicable diseases such as health system is responding to the needs of its ageing hypertension, type 2 diabetes, coronary heart disease population is therefore pivotal. and stroke as evidenced by the findings in the literature [20-22]. Caring for older people in the health care system: current This is hardly surprising as the prevalence of cardiovas- situation and challenges cular risk factors among the Malaysian elderly are increas- Malaysian health care services are provided by both the ing. In a large population based study, the prevalence of public and private sectors. The establishment of geriatric obesity among the elderly were 8.8% in males and 13.2% secondary care services has occurred since the mid in females [23]. Where else, the prevalence of abdominal 1990’s and was an important milestone in the care of the obesity in the 60-69 years age group was 23.2%, followed older patients [7]. Currently, there are 3 public hospitals by 19% in the 70-79 years group and 14.9% in the 80 years and 1 private hospital offering care for older patients [7]. and above group [24]. However, older persons who reside Rehabilitation centres are also being established through- in publicly funded shelter homes were found to be at risk out Malaysia. However, there are only 11 geriatricians of being undernourished and underweight [25,26]. available throughout the country and the majority are Visual impairment and blindness were noted to be based in Kuala Lumpur [37]. There is a constant chal- high in the older population and there is a need to lenge to recruit and retain key medical and allied health involve ophthalmic and optometric services as part of personnel in the public health sector, as many choose to comprehensive medical care in the community [27]. leavefor theprivate sectors. This furtherprevents Ambigga et al. Asia Pacific Family Medicine 2011, 10:2 Page 4 of 7 http://www.apfmj.com/content/10/1/2 expansion of secondary care support services into the non-government agencies [40]. Australia’s health services community. are grouped into five broad categories: public health ser- The expansion of services for older people in Malaysian vices; primary care and community health services; hos- primarycareisevenslowerdespitetheneedfor long- pitals; specialised health services; and goods such as term management of this vulnerable group in the com- medicine [41]. Funding is provided by the Australian munity. Older persons in Malaysia visit the public and Government through the national health insurance scheme (Medicare), state and territory governments, pri- private primary care services on an average of 6 visits per vate health insurers, individual Australians (out-of pocket year [38]. In view of this, primary care providers remain a payments) and a range of other sources [40]. popular first contact in the community. However, Malay- sian primary health care system, be it the public or pri- Primary care and community health services are usually vate sectors, remain oriented towards the care of acute, the first health services visited by a patient with a health episodic illnesses [21]. The health system remains passive concern in Australia. These services include GPs, private with older patient seeking treatment only when symp- dentists, pharmacists, physiotherapists and various other toms develop, leaving the need of older people with com- practitioners. The average number of visits for older plex and multiple chronic conditions unfulfilled [3]. Australians to their GP was 8.6 per person per year [40]. Although preventive and other specialised programmes Annual health checks for patients above 75 years old in for the older people in the community were planned, primary care are remunerated by Medicare. There are their implementation in public primary care clinics is also community based aged care assessment teams sporadic. The main impediment remains the shortage of (ACAT) to assess the elderly who may need special assis- a trained primary care workforce. Although there are tance [40]. The approval of these teams is a prerequisite approximately 10,000 primary care doctors currently i) for admission to Australian Government accredited manning the frontline of its public and private primary aged care homes, ii) to receive Community Aged Care health care systems, only around 400 are qualified family Package(CACP) where a care coordinator will manage medicine specialists [39]. Out of the 400, only 6 have the complex care needs of the recipient, iii) to receive an completed subspecialist training in community geriatrics extended Aged Care at Home(EACH) package where a [39]. Shortage of trained family medicine specialists and similar range of care services as CACP is provided, iv) to allied health personnel also hampers the deployment of receive an extended Aged Care at Home Dementia multidisciplinary primary care teams much needed to (EACH-D) package whereby the services is similar to EACH for people with Dementia; and v) for a place in a care for long term and complex health problems in the Transition Care Program (TCP) [40]. Most of these ser- community. Fragmentation of primary health care services into vices are delivered by highly trained multidisciplinary public and private sectors remains the greatest challenge care teams lead by 180 trained geriatricians and sup- in providing comprehensive, coordinated and continuous ported by the GPs throughout Australia [40]. care, especially for those with multiple chronic conditions and complex health care needs [21]. The absence of a The way forward: fundamental solutions needed to universal funding mechanism results in unequitable bridge the gap access to health care. The public primary care sector is Increased longevity is not only a triumph for a society often over-burdened and over-subsidised to provide care, but a huge challenge for health systems. Developed especially to the vulnerable groups such as older patients. countries have been facing challenges related to ageing In the private sector, health care costs for older patients for a long time and much is to be learnt from their with multiple and complex conditions are often too experience. Mainstreaming ageing into global agendas is expensive for them to bear the out-of-pocket payment. essential to prepare developing countries for the chal- The current fee-for-service payment to the private gen- lenge. Although Malaysia is still considered a country eral practitioners (GPs) by the private health insurance with a relatively young population, its ageing population companies and employers, results in limitation of care is steadily increasing. The cost of health care will for those with multiple and complex health care needs increase due to the escalating burden of chronic ill- who often require longer consultations and home visits. nesses in an ageing population. Proactive measures need Often, comprehensive care packages such as these are to be taken to contain these costs. not covered. These measures include restructuring the health care In comparison, the Australian health care system is also system. The recently announced proposal by the Malay- complex. There are many types of service providers and a sian government to set up a national health financing variety of funding and regulatory mechanisms in its scheme which will integrate all public and private pri- system. Services are provided by medical practitioners, mary care services under a common network of care allied health professionals and other government and [42], offers promise to the vulnerable population. It is Ambigga et al. Asia Pacific Family Medicine 2011, 10:2 Page 5 of 7 http://www.apfmj.com/content/10/1/2 hoped that the implementation of this scheme will pro- patients as passive recipients of health care no longer vide better coordination, continuity, equity and quality of holds true. Patient self management has been shown to care for older people and those with chronic conditions. reduce severity of symptoms [44] and was also found to be The 400 highly trained family medicine specialists are cost-effective [45]. Therefore, it is absolutely vital that in unique positions to champion patient-centred and patients are empowered with skills to manage their health, comprehensive primary care services under this new to enable them to work in partnership with their health care providers. This concept highlights a new paradigm in scheme. Focus should be shifted from providing care for clinical practice and therefore requires effective communi- self-limiting minor ailments to high quality preventive cation and behavioural change skills of doctors and allied care, chronic disease management and aged care. These family medicine specialists must also take a leadership health personnel, which further underscores training role in system redesign from a grassroots’ perspectives. needs in these areas for the primary care workforce. The numbers, however, are far from adequate as the pro- Older persons are fully entitled to have access to com- jected number of family medicine specialists needed to prehensive health care services which includes preventive deliver care to the population is 33,000 [43]. Therefore, care, curative care, chronic disease management and specific measures are currently being undertaken by the rehabilitative care. Preventive care for older people public universities and the Academy of Family Physicians involves health promotion and disease prevention Malaysia (AFPM) to produce more family medicine spe- throughout life which focuses on maintaining indepen- cialists in order to meet the country’sdemand. The dence and delaying the onset of disease. On the other Diploma in Family Medicine (DFM) should be an impor- hand, rehabilitative care involves improving the quality of tant first tier qualification for all primary care providers. life of older persons who already have disabilities. Some To become family medicine specialists, these clinicians useful lessons can be learnt from the Australian health should either possess the local Masters in Family Medi- system in caring for their older people. These include cine, FRACGP/MAFPM or MRCGP (UK) qualifications, conducting annual health checks for older population in as currently recognised by the National Specialist Regis- primary care. There is also a need to set up community ter for Family Medicine. based aged care assessment teams to assess the elderly High quality training for primary care doctors is vital to who may require special assistance since many of our ensure the delivery of quality chronic disease manage- elders are homebound. Comprehensive service packages ment and care of older people. The primary care curricu- for preventive care, self management support, chronic disease care and rehabilitative care for older people lum, both at the undergraduate and postgraduate levels, should be developed under the proposed healthcare should be revised to produce family medicine specialists who are not only clinically competent, but who can restructuring funded by the national health financing become effective gatekeepers, provide coordination and scheme. The role of secondary care geriatricians and continuity for long term health problems; and lead a psycho geriatricians should also be expanded to provide multidisciplinary primary care team. Malaysian medical better support to family medicine specialist on the schools should also incorporate geriatric medicine in ground to improve aged care services. their medical curricula to prepare future doctors to man- Development of efficient clinical information systems age our ageing population in the years to come. Geriatric by using electronic medical records would ensure long curriculum should also be included in the training of term coordinated care of older people in the community allied health personnel as there is a huge role for multi- [46]. In addition, integration of evidence based guide- disciplinary team based care management of older lines into patient care will be fundamental in translating people. evidence into practice [47]. Availability of highly trained allied health personnel is Apartfromimprovinghealthcareservicesfor older critical to support the deployment of a multidisciplinary people there is a need to develop a collaborative net- team in primary care. There must be a constant endeavour work with community resources. There is a necessity to to increase the numbers of highly skilled nurses, pharma- build more retirement villages; low level and high level cists, dieticians, physiotherapists, occupational therapist, care nursing homes and also a dire need to improve psychologists and other allied health personnel to deal facilities for the disabled and transportation for older with the challenge in managing chronic conditions in people in Malaysia. older people with complex health care needs. Assistance and training should be provided to the caregivers of older Conclusion people in the community by this skilled team. In conclusion, the challenges to care for older people in Health care workers must also ensure that older patients the Malaysian health systems are mounting. Major impe- and their families have adequate information and skills to diments include a shortage of specially trained physicians manage their health problems. The traditional role of and allied health personnel in both secondary and Ambigga et al. Asia Pacific Family Medicine 2011, 10:2 Page 6 of 7 http://www.apfmj.com/content/10/1/2 9. World Health Organisation: Country cooperation strategy at a glance. primary care sectors, fragmentation of health care 2010 [http://www.who.int/countryfocus/cooperation_strategy/ccs_mys_en. systems into public and private sectors; and absence of pdf], [Accessed 21 July 2010]. universal funding mechanisms to ensure accessible and 10. 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Bridging the gap in ageing: Translating policies into practice in Malaysian Primary Care

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Copyright © 2011 by Ambigga et al; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Population ageing is poised to become a major challenge to the health system as Malaysia progresses to becoming a developed nation by 2020. This article aims to review the various ageing policy frameworks available globally; compare aged care policies and health services in Malaysia with Australia; and discuss various issues and challenges in translating these policies into practice in the Malaysian primary care system. Fundamental solutions identified to bridge the gap include restructuring of the health care system, development of comprehensive benefit packages for older people under the national health financing scheme, training of the primary care workforce, effective use of electronic medical records and clinical guidelines; and empowering older people and their caregivers with knowledge, skills and positive attitudes to ageing and self care. Ultimately, family medicine specialists must become the agents for change to lead multidisciplinary teams and work with various agencies to ensure that better coordination, continuity and quality of care are eventually delivered to older patients across time and settings. Introduction population in Australia are healthier and better educated Population ageing remains a global phenomenon in this than their Malaysian counterparts. new millennium and is poised to become a major issue in Whilst the definitions of chronological age for the older developing countries. Malaysia, an upper middle income people in Malaysia and Australia are different, compari- country, with a population of 28 million is no exception son can still be made because chronological age is not a [1]. Its ageing population of 60 years and above is rising precise marker for the biological changes which accom- steadily from 5.7% in 1990 to 6.3% in 2000 and is expected pany ageing. The chronological age of 60 years and above to be 9.8% in 2020 [2]. Like other countries, population seems young in the developed world, but for a developing ageing in Malaysia is a result of declining fertility, falling country such as Malaysia where gains in life expectancy mortality rates and improvements in the health system. have not yet matched the developed world, this definition Effective prevention of infectious diseases and better nutri- is more appropriate [7]. Chronological age has little or tion has resulted in more people surviving into old age no importance in the meaning of old age in many parts [3,4]. Life expectancy among Malaysians has also risen to of the developing world [8]. Other socially constructed 71.7 years for men and 76.5 years for women in 2007 [5]. meanings of age may be more significant such as the Despite the improvement in life expectancy; poverty, lack roles assigned to older people. In some cases, it is the loss of roles accompanying physical decline which is sig- of education and poor social support tend to influence the nificant in defining old age. well being of its older population. In comparison to Australia, a developed country with A Malaysian burden of disease study conducted in 2004 22 million population, 13.3% of its populace are aged using disability adjusted life years (DALY) showed that the 65 years and over [6]. Life expectancy for Australian males five leading causes of disease burden were coronary heart is 79 years and for females is 84 years [6]. The older disease, mental illnesses, cerebrovascular disease, road traffic injuries and cancer [9]. This trend is similar to that * Correspondence: ambigga@salam.uitm.edu.my in Australia as the five leading causes of disease burden Discipline of Primary Care Medicine, Faculty of Medicine, Universiti using DALY in 2003 were coronary heart disease, anxiety Teknologi MARA (UiTM), 40450 Shah Alam, Selangor, Malaysia and depression, type 2 diabetes mellitus, cerebrovascular Full list of author information is available at the end of the article © 2011 Ambigga et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Ambigga et al. Asia Pacific Family Medicine 2011, 10:2 Page 2 of 7 http://www.apfmj.com/content/10/1/2 disease and dementia [10]. Hence, Malaysia is at an epide- hence different domains have been chosen by the var- miological transition where non-communicable diseases ious countries. Since there are dramatic variations in are now dominating its burden at a par with those of health status, participation and levels of independence developed countries. This pattern of disease is especially among older people of the same age in different coun- predominant among the older population in both tries, decision-makers need to take this into account countries [10,11]. when designing policies and programmes for their older As Malaysia progresses in its path to becoming a populations. developed nation by 2020, population ageing is inevita- ble and this will generate new challenges in terms of Comparing Aged Care Policies of Malaysia with Australia health and social services [11]. In view of this phenom- In most Asian countries, co-residing with an older rela- enon, this article aims to review the various ageing pol- tive and providing aged care is part of the cultural tradi- icy frameworks available globally; dissect various issues, tion. Policy makers in Asia aim at maintaining these policies and health services pertaining to the older cultural norms and values rather than developing poten- population in Malaysia; discuss the challenges of trans- tially expensive formal aged care programs and facilities. lating these policies into practice in the Malaysian pri- These policies focus on the older person remaining inte- mary care system; and consider fundamental solutions grated in society and being included in the formulation needed to address improving the health of older people and implementation of policies that affect their wellbeing in Malaysia. [3]. In Malaysia, a multi-sectoral and multidisciplinary approach was required to set up these policies and they Ageing policy frameworks available globally emphasized the sharing of responsibility between govern- Issues involving the ageing society in each country are ment, private sectors, non-government organisations, unique, resulting in the adoption of various frameworks community and the older people themselves in order to for ageing throughout the world. A number of these are meet their needs [18]. summarised in Table 1. There have been a number of national policies put in These frameworks cover various domains which place for older people in Malaysia. The first policy was include longevity, physical health, activities of daily liv- the National Social Welfare Policy (1990).This policy ing, autonomy, psychological well being, social relation- addressed the need for the care of older persons by ships, work participation, financial security, housing, families and communities [18].This was later strength- transport, safety, leisure activities, quality of life, age dis- ened with the National Policy for the Elderly (1995) crimination and attitudes [12-17]. These frameworks aimed at “creating a society of elderly people who are contented and possess a high sense of self worth and and their attendant policies help guide the development of relevant programmes, facilities and services around dignity, by optimising their self potential and ensuring them. that they enjoy every opportunity as well as care and These various policy frameworks for the different protection from members of their family, society and countries are designed based on the rights, needs, pre- nation” [7]. The National Council of Senior Citizen’s ferences and capacities of older people in each country Organization Malaysia (NACSOM), the Gerontological Table 1 Various ageing policy frameworks available globally Policy Definitions Countries frameworks Adopting Active Ageing Continuing participation in social, economic, cultural, spiritual and civic affairs by older persons and not United Kingdom (WHO) just being physically active or mere participation in the labour force [12]. and Europe Active Ageing Optimizing opportunities for physical, social, mental well being throughout life, in order to extend Malaysia (Adapted) healthy life expectancy, productivity and good quality of life as people age [13]. Healthy Ageing All Australians have the opportunity to maximise their physical, social and mental health throughout life. Australia Population health strategies promote and support healthy ageing across the lifespan. Information, research and health care infrastructure is available to support the healthy ageing of the Australian population [14]. Successful Multiple dimensions of functioning and wellness are measured and these include cognitive and affective Singapore Ageing status, overall physical health, social functionally and life engagement including life satisfaction. These will form the salient determinants of successful ageing [15]. Healthy Ageing A lifelong process of optimising opportunities for improving and preserving health and physical, social Canada and mental wellness, independence, quality of life and enhancing successful life-course transitions [16]. Positive Ageing Shine a positive light on ageing and older persons by recognizing their potential skills and ability rather New Zealand than their age [17]. Ambigga et al. Asia Pacific Family Medicine 2011, 10:2 Page 3 of 7 http://www.apfmj.com/content/10/1/2 Association of Malaysia (GEM) and others provide the There is also an increasing pattern of orthopaedic dis- impetus in developing these policies and services for eases in the ageing population [28] and functional older people in Malaysia [4]. impairment was found to be common among older peo- In contrast, ageing policy in Australia reflects different ple in the community [29]. Based on the NHMS III cultural norms and focuses on consolidating and progres- report, the greatest impact of functional independence sing reforms to ensure choice and access to quality aged in the elderly is on mobility, self care, housework and care services while relying on the role of informal support access to public places [20]. The survey also reported a higher prevalence of chronic pain in the elderly which [19]. In Australia, the focus is on ageing in place through interfered with their daily activities [20]. community support and services. Nevertheless this is changing towards person-centred approaches that pro- Another study also found that erectile dysfunction is mote independence. prevalent and this usually co-exists with type 2 diabetes Societal pressures and expectations are changing in and depression [30]. Urinary incontinence is an impor- Malaysia with an increasing number of older people tant and common problem and can lead to poor quality residing in the cities following the rural-urban migration; of life without timely management [31]. the changing pattern of families into nuclear types; and Psychological health problems are also prevalent among the changing role of women from caregivers to wage older people in Malaysia [32]. A community survey con- earners to support their families. Therefore, it is timely ducted in an urban area found that the prevalence of for Malaysia to revise its policies and be prepared to depression in the elderly was 6.3% [33]. The prevalence of invest morein qualityagedcareservicesinresponseto depression among the elders attending a health clinic was these changes in cultural norms and values. reported to be even higher at 18% [34]. In this age group, depression often co-exists with other chronic illnesses Health issues involving the ageing society in Malaysia [35]. This condition is common in primary care and there- Health issues pertaining to ageing are unique for each fore providers should play a key role in the detection and society. In order to gain a deeper understanding of the management [36]. health issues in the Malaysian ageing population, we The other non-health factors which should be conducted a comprehensive literature review of the addressed in Malaysia includes work, retirement and health and medical research involving Malaysian elders income, housing and institutionalisation, family and the using electronic databases including Medline, Google community, leisure and personal characteristics which Scholar, PubMed, Scopus and Web of Science. Based on can influence the quality of life of this vulnerable group [3]. These however, are beyond the scope of this paper. the published literature, ageing health issues in Malaysia In summary, published evidence has repeatedly high- can be summarised into 3 main domains - physical health, psychosocial health and nutritional problems. lighted that older Malaysian population suffers from mul- According to the Third National Health and Morbid- tiple and complex health needs which require holistic itySurvey(NHMSIII),chronic illnesses were reported and comprehensive long term care in the community. to be most prevalent (48.8%) amongst the 60 and above Despite this fact, Malaysia struggles to translate its poli- age group [20]. Malaysian elders are commonly affected cies into practice. A closer scrutiny of how the Malaysian by multiple chronic non-communicable diseases such as health system is responding to the needs of its ageing hypertension, type 2 diabetes, coronary heart disease population is therefore pivotal. and stroke as evidenced by the findings in the literature [20-22]. Caring for older people in the health care system: current This is hardly surprising as the prevalence of cardiovas- situation and challenges cular risk factors among the Malaysian elderly are increas- Malaysian health care services are provided by both the ing. In a large population based study, the prevalence of public and private sectors. The establishment of geriatric obesity among the elderly were 8.8% in males and 13.2% secondary care services has occurred since the mid in females [23]. Where else, the prevalence of abdominal 1990’s and was an important milestone in the care of the obesity in the 60-69 years age group was 23.2%, followed older patients [7]. Currently, there are 3 public hospitals by 19% in the 70-79 years group and 14.9% in the 80 years and 1 private hospital offering care for older patients [7]. and above group [24]. However, older persons who reside Rehabilitation centres are also being established through- in publicly funded shelter homes were found to be at risk out Malaysia. However, there are only 11 geriatricians of being undernourished and underweight [25,26]. available throughout the country and the majority are Visual impairment and blindness were noted to be based in Kuala Lumpur [37]. There is a constant chal- high in the older population and there is a need to lenge to recruit and retain key medical and allied health involve ophthalmic and optometric services as part of personnel in the public health sector, as many choose to comprehensive medical care in the community [27]. leavefor theprivate sectors. This furtherprevents Ambigga et al. Asia Pacific Family Medicine 2011, 10:2 Page 4 of 7 http://www.apfmj.com/content/10/1/2 expansion of secondary care support services into the non-government agencies [40]. Australia’s health services community. are grouped into five broad categories: public health ser- The expansion of services for older people in Malaysian vices; primary care and community health services; hos- primarycareisevenslowerdespitetheneedfor long- pitals; specialised health services; and goods such as term management of this vulnerable group in the com- medicine [41]. Funding is provided by the Australian munity. Older persons in Malaysia visit the public and Government through the national health insurance scheme (Medicare), state and territory governments, pri- private primary care services on an average of 6 visits per vate health insurers, individual Australians (out-of pocket year [38]. In view of this, primary care providers remain a payments) and a range of other sources [40]. popular first contact in the community. However, Malay- sian primary health care system, be it the public or pri- Primary care and community health services are usually vate sectors, remain oriented towards the care of acute, the first health services visited by a patient with a health episodic illnesses [21]. The health system remains passive concern in Australia. These services include GPs, private with older patient seeking treatment only when symp- dentists, pharmacists, physiotherapists and various other toms develop, leaving the need of older people with com- practitioners. The average number of visits for older plex and multiple chronic conditions unfulfilled [3]. Australians to their GP was 8.6 per person per year [40]. Although preventive and other specialised programmes Annual health checks for patients above 75 years old in for the older people in the community were planned, primary care are remunerated by Medicare. There are their implementation in public primary care clinics is also community based aged care assessment teams sporadic. The main impediment remains the shortage of (ACAT) to assess the elderly who may need special assis- a trained primary care workforce. Although there are tance [40]. The approval of these teams is a prerequisite approximately 10,000 primary care doctors currently i) for admission to Australian Government accredited manning the frontline of its public and private primary aged care homes, ii) to receive Community Aged Care health care systems, only around 400 are qualified family Package(CACP) where a care coordinator will manage medicine specialists [39]. Out of the 400, only 6 have the complex care needs of the recipient, iii) to receive an completed subspecialist training in community geriatrics extended Aged Care at Home(EACH) package where a [39]. Shortage of trained family medicine specialists and similar range of care services as CACP is provided, iv) to allied health personnel also hampers the deployment of receive an extended Aged Care at Home Dementia multidisciplinary primary care teams much needed to (EACH-D) package whereby the services is similar to EACH for people with Dementia; and v) for a place in a care for long term and complex health problems in the Transition Care Program (TCP) [40]. Most of these ser- community. Fragmentation of primary health care services into vices are delivered by highly trained multidisciplinary public and private sectors remains the greatest challenge care teams lead by 180 trained geriatricians and sup- in providing comprehensive, coordinated and continuous ported by the GPs throughout Australia [40]. care, especially for those with multiple chronic conditions and complex health care needs [21]. The absence of a The way forward: fundamental solutions needed to universal funding mechanism results in unequitable bridge the gap access to health care. The public primary care sector is Increased longevity is not only a triumph for a society often over-burdened and over-subsidised to provide care, but a huge challenge for health systems. Developed especially to the vulnerable groups such as older patients. countries have been facing challenges related to ageing In the private sector, health care costs for older patients for a long time and much is to be learnt from their with multiple and complex conditions are often too experience. Mainstreaming ageing into global agendas is expensive for them to bear the out-of-pocket payment. essential to prepare developing countries for the chal- The current fee-for-service payment to the private gen- lenge. Although Malaysia is still considered a country eral practitioners (GPs) by the private health insurance with a relatively young population, its ageing population companies and employers, results in limitation of care is steadily increasing. The cost of health care will for those with multiple and complex health care needs increase due to the escalating burden of chronic ill- who often require longer consultations and home visits. nesses in an ageing population. Proactive measures need Often, comprehensive care packages such as these are to be taken to contain these costs. not covered. These measures include restructuring the health care In comparison, the Australian health care system is also system. The recently announced proposal by the Malay- complex. There are many types of service providers and a sian government to set up a national health financing variety of funding and regulatory mechanisms in its scheme which will integrate all public and private pri- system. Services are provided by medical practitioners, mary care services under a common network of care allied health professionals and other government and [42], offers promise to the vulnerable population. It is Ambigga et al. Asia Pacific Family Medicine 2011, 10:2 Page 5 of 7 http://www.apfmj.com/content/10/1/2 hoped that the implementation of this scheme will pro- patients as passive recipients of health care no longer vide better coordination, continuity, equity and quality of holds true. Patient self management has been shown to care for older people and those with chronic conditions. reduce severity of symptoms [44] and was also found to be The 400 highly trained family medicine specialists are cost-effective [45]. Therefore, it is absolutely vital that in unique positions to champion patient-centred and patients are empowered with skills to manage their health, comprehensive primary care services under this new to enable them to work in partnership with their health care providers. This concept highlights a new paradigm in scheme. Focus should be shifted from providing care for clinical practice and therefore requires effective communi- self-limiting minor ailments to high quality preventive cation and behavioural change skills of doctors and allied care, chronic disease management and aged care. These family medicine specialists must also take a leadership health personnel, which further underscores training role in system redesign from a grassroots’ perspectives. needs in these areas for the primary care workforce. The numbers, however, are far from adequate as the pro- Older persons are fully entitled to have access to com- jected number of family medicine specialists needed to prehensive health care services which includes preventive deliver care to the population is 33,000 [43]. Therefore, care, curative care, chronic disease management and specific measures are currently being undertaken by the rehabilitative care. Preventive care for older people public universities and the Academy of Family Physicians involves health promotion and disease prevention Malaysia (AFPM) to produce more family medicine spe- throughout life which focuses on maintaining indepen- cialists in order to meet the country’sdemand. The dence and delaying the onset of disease. On the other Diploma in Family Medicine (DFM) should be an impor- hand, rehabilitative care involves improving the quality of tant first tier qualification for all primary care providers. life of older persons who already have disabilities. Some To become family medicine specialists, these clinicians useful lessons can be learnt from the Australian health should either possess the local Masters in Family Medi- system in caring for their older people. These include cine, FRACGP/MAFPM or MRCGP (UK) qualifications, conducting annual health checks for older population in as currently recognised by the National Specialist Regis- primary care. There is also a need to set up community ter for Family Medicine. based aged care assessment teams to assess the elderly High quality training for primary care doctors is vital to who may require special assistance since many of our ensure the delivery of quality chronic disease manage- elders are homebound. Comprehensive service packages ment and care of older people. The primary care curricu- for preventive care, self management support, chronic disease care and rehabilitative care for older people lum, both at the undergraduate and postgraduate levels, should be developed under the proposed healthcare should be revised to produce family medicine specialists who are not only clinically competent, but who can restructuring funded by the national health financing become effective gatekeepers, provide coordination and scheme. The role of secondary care geriatricians and continuity for long term health problems; and lead a psycho geriatricians should also be expanded to provide multidisciplinary primary care team. Malaysian medical better support to family medicine specialist on the schools should also incorporate geriatric medicine in ground to improve aged care services. their medical curricula to prepare future doctors to man- Development of efficient clinical information systems age our ageing population in the years to come. Geriatric by using electronic medical records would ensure long curriculum should also be included in the training of term coordinated care of older people in the community allied health personnel as there is a huge role for multi- [46]. In addition, integration of evidence based guide- disciplinary team based care management of older lines into patient care will be fundamental in translating people. evidence into practice [47]. Availability of highly trained allied health personnel is Apartfromimprovinghealthcareservicesfor older critical to support the deployment of a multidisciplinary people there is a need to develop a collaborative net- team in primary care. There must be a constant endeavour work with community resources. There is a necessity to to increase the numbers of highly skilled nurses, pharma- build more retirement villages; low level and high level cists, dieticians, physiotherapists, occupational therapist, care nursing homes and also a dire need to improve psychologists and other allied health personnel to deal facilities for the disabled and transportation for older with the challenge in managing chronic conditions in people in Malaysia. older people with complex health care needs. Assistance and training should be provided to the caregivers of older Conclusion people in the community by this skilled team. In conclusion, the challenges to care for older people in Health care workers must also ensure that older patients the Malaysian health systems are mounting. Major impe- and their families have adequate information and skills to diments include a shortage of specially trained physicians manage their health problems. The traditional role of and allied health personnel in both secondary and Ambigga et al. Asia Pacific Family Medicine 2011, 10:2 Page 6 of 7 http://www.apfmj.com/content/10/1/2 9. World Health Organisation: Country cooperation strategy at a glance. primary care sectors, fragmentation of health care 2010 [http://www.who.int/countryfocus/cooperation_strategy/ccs_mys_en. systems into public and private sectors; and absence of pdf], [Accessed 21 July 2010]. universal funding mechanisms to ensure accessible and 10. 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Journal

Asia Pacific Family MedicineSpringer Journals

Published: Mar 8, 2011

References