Primary Healthcare in Malaysia is indeed at the Crossroads of change in structure and financing. The Primary Care Providers’ Coalition (PCPC involving MMA, AFPM, PCDOM, Qualitas, KDM, & Society of FMS) are holding a Summit to highlight and discuss the coming changes.

Date: 14-15 AUGUST 2010
Venue:
ONE WORLD HOTEL
First Avenue
Bandar Utama City Centre
47800 Petaling Jaya
Selangor Darul Ehsan

Interested GPs and stakeholders can view the

Tip:
(click on the Full view link on the bottom menu bar to view the above in fullscreen. If you sign up for a free Slideshare account, you can also download the PDF from the menu)

This is exciting news:

A 1% tenofovir gel used intravaginally both before and after sex reduced the incidence of HIV infection among women by up to 54%.

For 20 years, researchers have been testing potential anti-HIV microbicides in humans, with no success. Now, the first of a new generation of antiretroviral-based microbicides has proven efficacious in a randomized, placebo-controlled trial conducted in both urban and rural South Africa.

A total of 889 sexually active, HIV-uninfected women (age range, 18–40) received either 1% tenofovir gel or placebo gel, with instructions to administer the gel intravaginally within 12 hours before sex and also within 12 hours after sex. Gel adherence was measured using returned applicators and was classified as either high (>80%), intermediate (50%–80%), or low (<50%). Mean follow-up was 18 months.

Overall, the study retention rate was 95%, and the average rate of gel adherence was 72%. In an intent-to-treat analysis, the incidence of HIV infection was 5.6 per 100 person-years in the tenofovir group versus 9.1 per 100 person-years in the placebo group, for an incidence rate ratio (IRR) of 0.61 (95% confidence interval [CI], 0.40–0.94; P=0.017). Efficacy correlated with gel adherence: Tenofovir reduced the incidence of HIV infection by 54% among women with high adherence, 38% among women with intermediate adherence, and 28% among women with low adherence. The tenofovir and placebo groups had similar rates of adverse events. Importantly, the women who became HIV-infected in the tenofovir group did not show evidence of tenofovir-related resistance mutations or thymidine analogue mutations.

Unpublished data presented at the 2010 International AIDS Conference (Abstract TUSS0502) showed that the tenofovir group also had a 51% reduction in the incidence of herpes simplex virus (HSV)-2 infection, apparently independent of the effect on HIV. The incidence of new HSV-2 infections was 9.9 per 100 person-years in the tenofovir group versus an alarming 20.2 per 100 person-years in the placebo group (IRR, 0.49; 95% CI, 0.30–0.78; P=0.003).

Comment: These solid data provide proof of concept that topical antiretrovirals can serve as effective anti-HIV microbicides. Given the efficacy and pharmacology of tenofovir in HIV treatment, and the positive animal studies leading up to this trial, the results should not necessarily be surprising, but they are most welcome. Additional trials are now needed to confirm these findings, including the reduced HSV-2 incidence. The ongoing VOICE trial, conducted by the NIH-funded Microbicide Trials Network, should provide additional efficacy data on tenofovir gel as well as oral tenofovir and oral tenofovir/FTC (Truvada) in the next 3 years. Other ongoing studies are now evaluating potentially more convenient or longer-acting modes of microbicide delivery, such as intravaginal rings, and additional antiretroviral classes. We are still far from having a microbicide available clinically, but at least, a female-controlled HIV prevention method finally looks possible.

And if that comes through, it would lend a strong helping hand to female-empowerment in preventing the spread of HIV! Truly exciting indeed.

The Star has a useful report which warns consumers to Be aware of health screening risks

Doctors and patients are encouraged to choose personalised and tailor-made health screenings over commercialised screenings, said an International Medical University (IMU) consultant physician.
Dr Verna Lee Kar Mun said every individual had different risk factors to certain diseases.
“Screening is an important aspect of prevention but not all diseases are suitable for screening,” said the IMU senior lecturer. She was giving a talk entitled “To Screen or Not to Screen?” at IMU in Bukit Jalil yesterday.
Dr Verna described the mass health screening programmes from hospitals, clinics, hotels and laboratories, sold in packages at different rates, as “commercialised”.
She advocated the need for both patients and doctors to take pro-active roles to ensure only proper and necessary health screenings were performed.

While it is indeed true that ideally any screening should be “individualized”, screening packages put together by laboratories make things easier for the practitioner and indeed possibly cheaper. What is also true is that some private labs may be pushing quite unnecessary tests of little or no value in so-called “comprehensive screening” packages (an example are the worthless “cancer markers” we blogged about)
Moral of the story : consumers be aware and always discuss with your doctors before being taken in for a ride by laboratories offering all these wonderful sounding “comprehensive blood test” screening packages.

Related posts:
Miracle Blood Tests?
One-Third Of Medical Screenings Performed Are Not Recommended
The RM1000 “Comprehensive check-up”

Shan has emailed to let us know that Malaysia’s TeleHealth initiative is very much alive. They have a website which explains about the TeleConsultation project. In principle, technology such as this, can help reach out to under-served areas for example rural-based doctors can consult specialists in bigger cities. In practice though there are enormous hurdles in implementing projects such as this, not only considering the infrastructure but also availability of human resources who are capable of carrying this out.
In our doctors’ forums, GPs quipped they are already carrying out TeleConsultation – using the good old telephone! I for one would be glad for simple things like people checking and replying their emails promptly, let alone real-time video conferencing and teleconsultation. When it comes to broadband, I think we have a long way to go, and perhaps we are even lagging behind our Asian neighbours. I remain somewhat skeptical how well Teleconsultation will perform given these constraints but I sincerely wish the project success, lest it turns out to be another waste of taxpayers’ money like the previous TeleMedicine debacle.

According to the Star, the Health Minister was quoted as saying Suspected dengue patients shouldn’t be sent home

Health Minister Datuk Seri Liow Tiong Lai, expressing concern over the management of dengue cases in hospitals, said he had received complaints that some suspected dengue patients were sent home while waiting for the test results, instead of being placed under observation.
“I see a number of cases where the dengue patient died in the hospital just after one, two or three days of being warded. I want them (doctors) to look into the cases of death, how to minimise death.

I hope the Minister checked with his medical advisors since he is not a medically trained doctor. Dengue patients have varying degrees of severity as far as the illness is concerned. Patients with milder forms of dengue and who are not so ill need not be admitted. Indeed if doctors were to follow the Health Minister’s advice and admit every “suspected dengue patient” then I can tell you his MOH hospital wards will be overflowing with unnecessary admissions. The MOH already has guidelines for Outpatient monitoring of dengue as well as Criteria for Admission (you can read these in the 2nd Edition of the Guidelines in PDF format) and I am sure the Minister is not suggesting we ignore the guidelines to follow his advice.
No one wants to see anyone die from dengue. In an endemic, there will be some very severe cases and despite all that can be medically done, there still will be some deaths. Perhaps the Minister should look into why public health measures are still sorely lacking that the breeding grounds for Aedes are still rampant in our urban areas. That is where the solution lies, not indiscriminate admission of all suspected dengue patients.

Related MMR posts

The NST has this article which claims Healthcare will be “for FREE”

To ensure all Malaysians get adequate healthcare, wage earners will have to make scheduled monthly contributions to the proposed National Health Financing Scheme. The self-employed, those who have an independent income as well as employers would also have to contribute, Health Minister Datuk Seri Liow Tiong Lai told the New Sunday Times.
The government proposes to set up a health financing scheme that will give all Malaysians access to primary healthcare at any public or private clinic for free.
The scheme will also look at secondary healthcare coverage and the illnesses and treatments it might be able to cover, said Health Minister Datuk Seri Liow Tiong Lai.
Although much of the scheme has yet to be finalised, the rate of contributions
is expected to be based on wage scales, in which the rich will pay more. The poor will not have to contribute to the scheme but will still be covered.
“It works on the principle of the rich helping the poor, the able helping
the disabled, the young helping the old, and the healthy helping the unhealthy. All kinds of illnesses will be covered under this scheme so that everyone will have access to good adequate healthcare,” Liow said.
The funds will be administered by the proposed National Health Financing Authority, a statutory body under the ministry. New legislation may have to be passed and existing ones amended to make way for this scheme.
Regardless of how much one contributed, everyone would enjoy the same standard of care, said Liow.
Only workers aged 18 and above with an income that has reached a certain threshold, need to contribute.
Children will be financed by their parents. The poor and disabled who have no income or whose income does not reach the threshold need not contribute.
For those who wish to stay in a suite rather than a standard room, they will have to pay the difference.

So while the headlines tries to put a positive “spin” on things, in reality consumers will be “forced” to contribute to the National Healthcare Financing Scheme, something we have blogged about for a long time, but has not materialised. It seems it will not happen just yet, but in stages and the whole process could take “about 10 years or more” according to the Health Minister. He is upbeat about it and believes the whole thing can be done in “four phases”

The first phase is strengthening the healthcare system like governance and standards of care; the second is to grant more autonomy to primary healthcare providers in areas like human resource and management; the third is to integrate all public and private clinics so that they are all linked under a common network so that people can access either one; and the fourth phase will be the introduction of the national health insurance under the national health
financing scheme.

The integration of public and private clinics may begin sooner than you think and GPs may now be faced with a financing system based on Capitation whereby they are paid not as “fee for service” but according to a fixed number of patients allocated to them, irrespective of how many visits patients make to their GPs (which in turn has its upsides and downsides if you read the Wikipedia link). From the discussion in the MMR doctors forums, there is some concern that this may spell the end of 24 hour clinics and that instead of “walk-in” visits to your GPs, capitation based patients might be seen only by appointments. Solo GP practices are less likely to survive under a Capitation scheme and ultimately the winner will be large group practices.
Not everyone is enthusiastic about the proposed Healthcare scheme and some say it is “frightening” and prefer the status quo.

“What frightens us is that nothing is ready, nobody knows about the scheme,” said Selangor state executive councillor Dr Xavier Jayakumar today.
Under the country’s current health care system, Malaysians can seek medical treatment at a public hospital with just RM 2 for registration.
Consultations and medications are provided for free.
Under the new scheme, Xavier said that an uninsured person would have to pay consultation fees and for medications at market rate.
Pointing out that 70 per cent of the population had household incomes of less than RM 3,000, he said most would not be able to afford medical treatment.
“You have to have a very clear scheme on how the poor, the unemployed, the lower income population is going to benefit from the new scheme,” he said.

There is an Internet acronym – TANSTAAFL – which stands for There Ain’t No Such Thing As A Free Lunch. In healthcare nothing could be further from the truth. Healthcare is not free. It is expensive business and at the end of the day someone has to foot the bill. What the Government is trying to do is to shift the payment responsibility directly on the consumer rather than indirectly via public funding which is paid for mainly by taxes and other Government revenue. We are at a cross-roads as far as healthcare financing goes. Whatever the outcome I hope a sensible balance is reached and the poor are not burdened.

The Star reports:

More men are enrolling in nursing courses in Johor, as there is a huge demand for the profession in the state.
Women, Family, Community Development and Health Committee chairman Dr Robia Kosai said that the state was facing a shortage of nurses and many men were taking the opportunity to join the profession.
“We currently have about 75 male nurses who are usually assigned for duties that need physical strength such as carrying disable patients,” she said when replying to a question posed by Datuk Ng See Tiong (BN – Parit Yaani) at the state assembly sitting here Monday.
Ng then asked what male nurses who have served for five years and were upgraded to the status of Sister would be called.
“Don’t tell me that senior male nurses are going to be called Sisters too,” he said adding that a survey should also be done to gauge if male nurses were as effective as female nurses.
“Female nurses have sweet smiles that can soothe patients but what can a male ones offer?” asked Ng.

What can male nurses offer? Well, Datuk Ng, a lot. Perhaps you can watch this video:

and Datuk Ng, the term is not “Sister”, it would be Nurse Manager. It’s not just in Johor but everywhere in Malaysia, nursing schools are seeing more male applicants. Men are realising that there is a career in nursing. It’s not a “feminine” job anymore and there are important roles men can play as nurses.

NS writes in:

What are the options available for students that are kicked out from medical schools? Can they be re-admitted back in the same University? and if, their appeals are rejected, can
they still continue to pursue medicine at other medical schools?

Students get kicked out of medical school usually for failing badly at exams and that is usually after given one or more chances repeating. Less commonly it is because of disciplinary reasons. IN either case I think it is very unlikely that they will be re-admitted to the same University. There is nothing to stop students from applying to other medical schools. Who knows, one might succeed eventually?
Do bear in mind there are fields other than medicine which hold promising careers such as pharmacy and biomedical sciences. Medicine is still very competitive despite the fact that there will be an oversupply of doctors in the coming years. I think this is something students should think about when deciding on their careers.

A patient was referred by an ophthalmologist for “saggy eyes” which appeared to be a bit “bruised”. Her platelet count was mildly low at 136×10^9/l.

What is the diagnosis?
What further investigations would you do?

OK, might be a little difficult this one, so here are some clues.

1) The patient volunteered that she has been having weakness in the legs of late.
2) Look carefully at her hands, especially the dorsal aspect.
3) Think of a flower.

In the Nutgraph today : Private healthcare: Too expensive?

Universiti Malaya political economist Associate Professor Dr Terence Gomez says declining standards in government sectors have led the middle class to look for ways to bypass the public system.
“The promotion of medical insurance has led to private healthcare being more affordable for the middle class,” he tells The Nut Graph in a phone interview. Rising private healthcare costs, however, have led to higher insurance premiums, coupled with lower coverage.
Gomez says escalating private healthcare costs is therefore a political issue as well as an economic one. “The government faces a potential backlash from the middle class who don’t want to pay huge insurance premiums and yet are not willing to return to the public health system,” he says.
“This is an issue of concern for the [Barisan Nasional] government, which is already facing declining middle-class support.”

It is interesting that there is little talk of capping hospital charges which are distinct from doctors’ professional fees. Will capping charges (as opposed to leaving it to market forces) in any case be counter-productive for all concerned? I doubt it will ever happen if you read between the lines.

To complicate matters further, Dr Quek says the government, in fact, owns some of the large corporations that have entered the private healthcare business. “Khazanah Nasional owns 60% of the Pantai-Gleneagles group, while KPJ is wholly owned by the Johor state government. Since they’ve entered the market, they’ve been aggressively pushing profit margins higher and higher,” he says.

It will be a never ending problem until there is a comprehensive National healthcare financing system, perhaps something like the Australian Medicare system. This will take a lot of effort and political will power. People’s health and indeed lives are at stake the longer politicians dilly dally on this extremely important matter.

Nice slide presentation by Dr. Chew. Best viewed Full screen size – just click on the Menu at the bottom left of the Slideshare window for this option.

So he was asked to demonstrate as ABG is needed for one patient.
He took the needle, inserted it to patient’s wrist at an obviously wrong site for radial artery, and obtained nothing but some air. (Specialist and MO frowned, thought he was going to withdraw and re-attempt).

Surprisingly, he pulled out the needle like ending a procedure, passing it to the nurse, “Go and analyze this in the ABG machine…”

Specialist stopped him, “What are you going to analyze there? It’s just air!”

And he said, “Ya, you asked me to take arterial blood GAS right? I got it!”

via Dr. Darren

There are now about 30 medical schools in this country. One wonders what the quality of the training is for some of them. While this incident has it’s funny side, it only goes to show how deficient in knowledge and understanding of basic medicine some of today’s HOs can be.