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Aust J Rural Health2002v10n2 - KamilMA
Aust J Rural Health2002v10n2 - KamilMA
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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
IN
OFPty
MALAYSIA:
RURAL
Health
Ltd HEALTH
K. M. ARIFF and C. L. TENG Review
BEES SGML
Article
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.
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
Malay, Chinese, Indian, Thai and aboriginal systems. hypercholesterolemia and hypertension have also been
Despite the wide availability of modern scientific health- reported.18
care services that are accessible to Malaysia’s rural and Factors such as rural poverty, ignorance, behaviour,
remote populations, traditional healthcare services are culture and the status of women have adversely influ-
still used by Malaysian communities for a variety of enced the use of rural healthcare despite the govern-
health and psychosocial problems.5 The popularity of the ment’s best efforts to provide access to modern
services of the traditional healer particularly for the treat- healthcare. Thus, differentials in health status continue to
ment of musculoskeletal problems, psychological illness exist between urban and rural Malaysian communities.
and illness perceived to be supernatural in origin Diseases such as malaria, tuberculosis, leprosy, mild
(charms, witchcraft, evil spirits) is widely acknowledged and moderate forms of malnutrition, pregnancy-related
by rural communities and conforms to the author’s (a rural problems, obstructive airway disease, injuries and psy-
family physician) personal observation.12,13 chiatric illnesses are still issues of concern to rural
healthcare providers.6 Outbreaks of infectious diseases
Morbidity in rural communities like typhoid and cholera do occur sporadically. The control
The rural Malaysian community perceives health as a of dengue fever remains a significant problem both in
feeling of well-being and an ability to participate in social urban and rural areas.
activities – a feeling of harmony that helps a person
integrate into his or her environment and interact with THE FUTURE
community members. It is the author’s view that this notion
of health often leads to asymptomatic health problems Malaysia has done remarkably well in establishing an
like hypertension, diabetes, hyperlipidemia and anaemia extensive network of rural healthcare services and deliv-
being left untreated until complications arise. ering cost-effective healthcare as a vital part of the
The National Health and Morbidity Survey (NHMS) nation’s socioeconomic development. Any future strat-
conducted in 1996 that measured both the felt and egies to enhance rural health should continue to be a
expressed needs of the population showed that the rural collaborative effort on the part of the Ministry of Health
population had a higher prevalence of recent illness and and other government and non-government agencies. The
physical disability.14 The percentage of adults with pre- relationship of health with every other aspect of rural
viously undiagnosed hypertension was higher in rural life should be the guiding principle with clear strategies
localities. Prevalence rates for current smokers and aimed at reducing rural poverty, enhancing literacy,
alcohol drinkers were also significantly higher in the rural changing lifestyle and dealing with the social inequalities
population than in urban areas. Rates for Pap-smear that affect the status of rural women.19 Strategies targeted
examination and breast self-examination were lower in to improve rural health should be planned with adequate
rural populations. Overall, only 26% of Malaysian and active community participation and empowerment to
women had ever had a Pap-smear done (28.4% for urban initiate lifestyle change and discard unhealthy traditional
women and 22.8% for rural women). The NHMS also beliefs and practices. Studies on the Malaysian Aboriginal
reported a lower percentage of rural residents had sought population (Orang Asli) have shown that greater commu-
healthcare for their recent illness or injury though they nity participation in efforts to promote immunisation,
had felt a need to seek care. family planning and improved nutrition were more likely to
The rapid pace of economic activities, such as, be culturally sensitive and friendly and bring about better
logging, jungle clearing for construction of highways, hydro- health outcomes.20 ‘The Kuching Statement on the Health
electric projects and townships has had a negative impact of Indigenous Peoples’ affirmed the need for health pro-
on the health of the Aboriginal population. Their tradi- fessionals to receive training in indigenous health issues
tional lifestyle has been disrupted. Their resettlement to and adequately address the health of indigenous women
new areas has contributed to the deterioration of their in particular.21
physical and emotional health, and adversely affected the Plans are being identified to reshape the future of the
nutritional status of children.15–17 Food taboos, ignorance, Malaysian health system from one that is illness and dis-
disruption of traditional value systems and lack of access ease focused to one that is wellness focused. A telemedi-
to the foods that were once available in their traditional cine pilot project in Sarawak was initiated in 1997 to test
habitats have contributed to their poor nutritional status. the practicality of providing telemedicine (teleconsulta-
On the other hand, health problems that are associated tion and teleradiology) by linking six district hospitals
with a sedentary lifestyle and overnutrition, such as obesity, that lacked infrastructural development and specialist
RURAL HEALTH CARE IN MALAYSIA: K. M. ARIFF AND C. L. TENG 103
services via Internet to the Sarawak General Hospital. 9 Sarawak Medical Department Report. Flying. Doctor Service,
Within a 2-week period, it was clear that the Internet was in Sarawak. Mimeographed document of the Sarawak.
a viable and cost-effective medium with significant Medical Department 1981, Malaysia.
savings on travelling costs for patients referred to hospitals, 10 Taha MA, Tening H. The Flying Doctor Services in Sarawak
– a Review 1975 –1987. Sarawak Medical Department,
telephone charges, travelling time for specialists and a
Kuching, Malaysia, 1988.
viable technology for continuing medical education.22
11 Sarawak Health Department Report. Health Facts. Sarawak
Plans are being formulated to extend telemedicine ser-
Medical Department, Kuching, Malaysia, 2000.
vices to all health clinics. The telemedicine project in 12 Kamil MA. Preferential utilization of healthcare systems by
Malaysia is seen as an important means of achieving a Malaysian rural community for the treatment of muscu-
health for all rural people. loskeletal injuries. Medical Journal of Malaysia 2000; 55:
451–458.
ACKNOWLEDGEMENTS 13 Chen PCY. Medical systems in Malaysia cultural bases and
differential use. Social Science and Medicine 1975; 9:
The authors wish to thank Associate Professor H. Yadav 171–180.
14 Maimunah AH, Sararaks S, Low LL, Zulkarnain AK, Tahir A.
from the Department of Social and Preventive Medicine,
Identifying needs of rural people: Results of the National
University Malaysia and Dr M. K. Rajakumar for their
Health and Morbidity Survey in Malaysia. Proceedings of
helpful comments in preparing this article.
3rd Wonca World Conference on Rural Health, Academy of
Family Physicians Malaysia, Kuala Lumpur, 1999, 13 –16.
REFERENCES 15 Norhayati MM, Noor Hayati MI, Nor Fariza N et al. Health
status of Orang Asli (aborigine) community in Pos Piah,
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