6.1 Introduction
Disease prevention and control programmes aim to reduce disease incidence, prevalence, and morbidity or mortality (Reference DowdleDowdle, 1998). Within the first thirty years since independence in 1957, Malaysia successfully eradicated or drastically reduced the occurrence of several serious communicable diseases (CDs) (Figure 6.1). During the next thirty years, Malaysia had some success as well as limited or no progress in dealing with non-communicable diseases (NCDs), re-emerging CDs (such as dengue) and other new and emerging CDs (such as influenza H1N1). This chapter analyses the development and evolution of disease control in Malaysia over the sixty years since independence (1957–2017). It explores and analyses the influences and interactions of various components of the health system and beyond the healthcare system in controlling diseases. The chapter does not attempt to address all the threads of disease control efforts in Malaysia. Instead, specific examples of disease control programmes illustrate key features that contributed to the success or limited progress of control efforts.
Disease control programmes in low- and middle-income countries commonly use vertical or campaign-style programmes. Horizontal programmes, on the other hand, rely on a system of health services. Reference Atun, Bennett and DuranAtun, Bennett and Duran (2008) discuss the advantages of vertical programmes (rapid response; quick, economical and efficient solutions; better accountability within limited resources and timeframe) and constraints (donor- and value-driven (responsive to disease, lacking in people-centred care); expensive to sustain; creating subsequent redundancies, inefficiency and fragmentation in the health system). They note that some vertical programmes are standalone, completely separate and parallel to mainstream health services, and continue to remain in that mode. Others are designed as time-limited programmes that are then integrated with extant health services; yet others have varying degrees of integration from inception.
This chapter describes Malaysia’s developmental experience in disease control and explores how the characteristics of prevalent diseases and the health system have combined to influence the design of disease control programmes and their subsequent integration into the mainstream health service.
6.2 The First Phase (1957 until the Mid-1980s): Control of Communicable Diseases
By the time it gained independence, Malaysia had already controlled several major epidemic contagious diseases (smallpox, cholera, plague). The main CDs of concern were vaccine-preventable diseases (neonatal tetanus, diphtheria, pertussis (whooping cough)), which took a heavy toll of infant lives; vector-borne and water borne diseases (malaria, dysentery, typhoid and paratyphoid, and endemic cholera), which affected the productivity and lives of the work-aged population groups; and tuberculosis (TB), which caused illness and premature death in both adults and children (Box 6.1).
Malaria and TB were the fifth and sixth leading causes of hospital admissions and deaths, respectively (Supplementary Table 6.a) (Reference Ismail and MartinezIsmail & Martinez, 1974; Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.).
TB: An estimated 25% of all hospital beds were occupied by TB patients, most lt in advanced stages of the disease, and 75% of children had been infected by age 15 (MAPTB, 2012).
Malaria:
A 1965–66 survey showed 168,500 malaria cases reported from static and mobile clinics in Peninsular Malaysia, an annual 40,000 cases in Sarawak and 250,000 cases in Sabah (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.).
Yaws was reported at 140.85 per 100,000 population in 1958 (Reference LoLo, 1985).
Filariasis was present in 20,000 of 600,000 people clinically examined between 1960 and 1984 (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.).
Leprosy: An estimated 11,900 to 15,000 cases in Peninsular Malaysia in 1969 (Reference KamaludinKamaludin, 1990).
Tetanus, diphtheria, pertussis, poliomyelitis and measles contributed to high infant and child mortality rates (Figure 6.1 and Supplementary Table 6.b).
See Supplementary Tables 6.a, 6.b and 6.c for further information.
As elaborated in Chapters 3, 4 and 5, during the 1960s until the mid-1980s, healthcare for the predominantly rural population increased gradually, with expanding rural health centres and district hospitals and gradually increasing availability of nurses, midwives, hospital assistants (later known as assistant medical officers) and sanitation staff. Training and competence in public health and programme management was limited and concentrated mainly at the national and state levels. Monitoring systems were rudimentary. The high incidence and prevalence of the common CDs was a heavy burden for the nascent health services. The rationale for adopting vertical approaches for controlling selected CDs was to provide additional resources targeted at rapidly reducing specific disease burdens to enable the young health service to assume responsibility without being overcome by these diseases to the detriment of other functions.
A distinctive feature of Malaysian development was that disease control programme funding was from domestic sources and channelled through the budget allocated to the Ministry of Health (MoH). Malaysia generally does not receive significant bilateral aid for health (World Health Organization, 2017). Foreign aid was mainly in terms of consultant expertise for designing programmes and training staff, management and treatment protocols, and designing monitoring and surveillance systems. Therefore, the new programmes aligned as closely as possible to national health development strategies. There was no need to provide accountability to external donors. On the other hand, there were strong incentives to avoid unnecessary domestic financial burdens by using existing facilities and staff and avoiding human resource issues arising from redundant staff.
The factors that influenced the design of prevention and control programmes included:
the access of affected population groups to, and coverage provided by, the rural health service and public sector hospitals
the availability and technical skills of the staff in those facilities
the management capacity of the health services
the clinical nature of the diseases in question, which partly influenced how and when those who were affected made contact with health services
the epidemiological characteristics of the diseases in question, for example, the mode of transmission, the types of vectors and their habits, and the habits and lifestyles of human population groups
the availability of effective and affordable technology or medical products to address the diseases
The initiatives for preventing and controlling CDs during this period could be categorised in three groups:
1. No dedicated ‘programme’, for example, waterborne diseases, such as endemic cholera, typhoid and paratyphoid.
2. National programmes (or campaigns) with dedicated organisational entities for planning, training, monitoring and evaluation but service delivery through the mainstream health services. Examples are the vaccine-preventable diseases of childhood and TB.
3. National- or state-level programmes with dedicated management structures as well as service delivery mechanisms. Examples include vector-borne diseases such as malaria and filariasis.
Table 6.1 illustrates the key features that differentiated the various degrees of verticality in the spectrum of vertical programme designs.
Table 6.1 Examples illustrating key features in the spectrum of Malaysian vertical disease control approaches that subsequently merged with mainstream health services (see Supplementary Table 6.c for programme details)
| Examples of vertical disease control programmes | |||
|---|---|---|---|
| Vaccine-preventable diseases of childhood | Tuberculosis | Malaria | |
| Pressures that led to the adoption of national programmes | Professional and political awareness of the value of vaccines, influence of the WHO and availability of affordable vaccines | Strong advocacy by civil society (MAPTB) leading to political awareness and commitment | International pressure to move from control measures (based on species sanitation in cities and rubber estates) to nationwide eradication to avoid becoming a pool of infection dangerous to neighbouring countries |
Key organisational features of vertical national programmes at inception: |
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| Duration and criteria for merging vertical programmes into mainstream health services |
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Dedicated vertical programmes were suited for diseases that required the delivery of medical care (immunisation, diagnostic, medication) to specific target population groups or measures aimed at disrupting the lifecycle of specific vectors. In contrast, waterborne diseases required environmental control approaches coupled with surveillance and outbreak control. Therefore, instead of a dedicated disease-specific vertical national programme, preventing waterborne disease was the responsibility of environmental health services (see Chapter 7), while surveillance and control of disease outbreaks was the purview of mainstream health services for CD epidemiology and control.
6.2.1 Socio-economic Development Influenced the Development of Disease Control Programmes
The overall improvement of the country’s socio-economic and living conditions (see Chapter 3) facilitated the successes in controlling CDs. The gross domestic product (GDP) per capita increased substantially, with an annual growth of 7.7% between 1970 and the mid-1980s, improving standards of living for the majority of the population, making them less vulnerable to infectious diseases (Reference Tan, Kwok, Tan, Nagaraj, Tey and ZulkifliTan et al., 1987; UN Country Team, 2005). Significant improvements in roads and transportation made healthcare more accessible.
In addition to economic growth and infrastructure development, social development also progressed. The percentage of women (aged 15–19 years) who attended secondary school increased from 15% in 1960 to 75% in 1980, while the percentage of living quarters with piped water and flush toilets rose from 48% and 18% in 1970 to 68% and 60%, respectively, in 1980 (Reference Tan, Kwok, Tan, Nagaraj, Tey and ZulkifliTan et al., 1987). The increase in women’s education levels as well as improved environmental health contributed to the decline of infant mortality caused by CDs; in particular, vaccine-preventable diseases and food-borne and water borne diseases (Reference DaVanzo and HabichtDaVanzo & Habicht, 1986).
6.2.2 Programmatic Features that Influenced Outcomes
6.2.2.1 Collaborative and Co-ordinated Activities at Various Levels of Service Delivery
The national disease control programmes carried out promotion, prevention and early detection activities (education, vaccination and case detection) mostly at the primary care level. In the rural health units, disease control activities complemented maternal and child health and outpatient care, sanitation and environmental health services, and dental care. District and general hospitals served as training, treatment and referral centres. For example, hospitals supported rural health units by providing training for bacillus Calmette-Guerin (BCG) vaccination and served as referral points for case finding and contact tracing for TB control programmes (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). The dedicated management teams of the national disease control programmes played a critical role in aligning and co-ordinating disease control funding, strategies, processes, activities and services across different actors, sectors, levels and facilities. For example, TB managerial teams were formed at state level to provide continuous supervision, consultation and support and to ensure seamless co-ordination at all levels of care with available resources (Reference Ismail and MartinezIsmail & Martinez, 1974; Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.).
The rapid expansion of rural health facilities and services between the 1960s and 1970s and its linkages to district and general hospitals contributed to the reduction of morbidity and mortality from CDs. However, most of the disease control programmes included a unilateral (one-way) referral system from clinics to primary/district hospitals or national referral hospitals, and this system soon became established as the norm in the health services. The lack of a counter-referral system was workable when the country dealt with CD control that mainly required acute care and response. However, it would later create difficulties in the management of patients with diseases that required long-term care, such as NCDs and HIV.
6.2.2.2 Human Resources
Similar to the public sector health services, the disease control programmes relied on allied health personnel, including nurses, medical assistants, medical laboratory technologists and junior laboratory technicians rather than doctors. As discussed in Chapters 4, 5 and 8, this strategy enabled Malaysia to reach wider populations, especially those in rural areas, while there was a shortage of medical professionals. The allied health personnel received technical information and skills training and acted as front-line staff. For example, junior laboratory technicians trained by the Institute for Medical Research (IMR) did most of the sputum examination for TB (Reference CheongCheong, 2010). Allied health staff from rural health clinics assisted in case detection for malaria screening (Reference Jaafar, Suhaili, Mohd Noh and LeeJaafar et al., 2007). Not only did the front-line staff provide medical care, they also raised community awareness regarding early detection and treatment.
Staff employed by or deployed to the national disease control programmes were mostly from the same categories as those in the health services, and qualifications and employment conditions were the same. By the time the vertical programmes merged into the mainstream health services, economic and health service growth created the need for more of these personnel as well as the capacity to absorb them. Thus, career paths and absorption were not problematic, and the issue of redundancy was avoided.
6.2.2.3 Surveillance Systems
Each disease control programme developed a tailored surveillance system. For example, a central TB registry established in 1973 under the National TB Control Centre monitored TB cases. Chest clinics in hospitals in each state collected and compiled data for submission to the national level. The malaria eradication programme had a case registry system and entomological surveillance activities. Similarly, leprosy had a surveillance system.
Meanwhile, a standard epidemiological surveillance system had been developed for the Epidemiology Unit since 1971 (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). The separate surveillance systems were integrated into the standard epidemiologic surveillance system of the MoH during late 1980s and early 1990s when the vertical programmes merged into the mainstream. Although Malaysia has not evaluated the impact of the separate surveillance systems, it is possible to conjecture about both their advantages and their constraints. The dedicated surveillance and monitoring systems of the disease control programmes were probably of better quality because of special efforts in training, tighter supervision and less staff mobility. However, they would have created duplication and an additional burden on the reporting staff, particularly at the front line. However, the skills and experience gained through the better-quality surveillance in the vertical programmes probably carried over to the mainstream health services when the programmes merged.
6.2.2.4 Community Education and Mobilisation
The disease control programmes used the same strategies of community mobilisation and education as used successfully in primary healthcare (PHC), using local community organisations, particularly in rural areas (see Chapter 4). Also, the MoH programmes partnered with major non-governmental organisations (NGOs), which earlier had advocated for national disease control efforts, mobilised funding from civil society and developed care models. Examples are the Malaysian Leprosy Relief Association (MaLRA) and the Malaysian Association for the Prevention of Tuberculosis (MAPTB). Evidence of the success of such efforts is, for example, the fact that over 80% of registered TB cases in 1975–79 were self-referred by symptom-motivated patients (Reference CheongCheong, 2010). Not only did such partnerships address ignorance, scepticism and cultural prejudices, they also established practical measures for facilitating and supporting individuals and families to benefit from the disease control efforts. Examples include the provision of a TB allowance to compensate for travel and sickness absenteeism, and the provision of living allowances as well as housing and income-generation opportunities in sheltered communities for cured leprosy patients who carried the stigma that isolated them from their own communities (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.).
However, there were failures. For example, resistance by the population in Sabah to spraying with DDT (dichlorodiphenyltrichloroethane) under the malaria control programme in the 1980s is attributed to the lack of engagement with the communities and failure to understand local needs and concerns (Reference RahmanRahman, 1982; Reference Mak, Jegathesan, Lim, Hakim, Rain, Ambu and ChongMak et al., 1992; Ministry of Health et al., 2015).
6.2.2.5 Introduction and Availability of Vaccines and Effective Medicines/Medical Products
The introduction of new technology, vaccines and medicine contributed to the prevention, early detection and control of CDs. The incidence of childhood TB declined sharply in the 1970s after the introduction of the BCG vaccination programme (Reference CheongCheong, 2010). Effective treatment such as single-dose penicillin with 2% aluminium monostearate (PAM) for yaws (Reference LoLo, 1985), multiple drug therapy (MDT) for leprosy and a shorter duration of TB treatment (from two years to six months) led to reductions in morbidity (i.e. deformity among leprosy patients) and mortality rates (Reference LoLo, 1985; Reference JayalakshmiJayalakshmi, 1994; Reference CheongCheong, 2010). The IMR played a significant role in introducing new vaccines and diagnostic tests in the early days (Box 6.2).
The production of vaccines for cholera, typhoid, plague, smallpox and rabies was started by the IMR in the 1940s (Reference Ramanathan, Cheah and DonderoRamanathan et al., 1976). The IMR initiated field trials and developed them as a standard protocol before any new vaccines were released to the public. In 1986, a trial on measles vaccines was conducted by the MoH and supported by the IMR before it was included as part of the national immunisation programme (UN Country Team, 2005).
The IMR acted as a central reference laboratory for the whole country for more specialised diagnostic and public health laboratory tests for diseases such as yaws, typhoid and cholera (Reference Ramanathan, Cheah and DonderoRamanathan et al., 1976).
6.2.2.6 Outcomes
The BCG vaccination programme realised its initial objective of providing at least 75% coverage of the susceptible population within a short period (Reference Ismail and MartinezIsmail & Martinez, 1974). The mass survey and treatment campaign with PAM under the yaws control activities also reduced the reported cases from 9,462 in 1958 to 335 in 1968 (Reference LoLo, 1985).
The incidence of most CDs declined dramatically (Figure 6.1). The incidence of TB declined from 151.5 per 100,000 population in 1961 to 56.8 per 100,000 population in 1985 (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.); malaria cases reduced significantly from 150,000 to below 50,000 in the late 1970s, but the goal of disease eradication had yet to succeed fully (Reference Mak, Jegathesan, Lim, Hakim, Rain, Ambu and ChongMak et al., 1992). Yaws and filariasis were no longer a concern; the country had successfully eliminated leprosy in 1994 and achieved polio-free status in 2000 (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). With the increase of childhood immunisation coverage (Table 6.2), the infant and child mortality rates had also declined significantly in 1990 (Table 6.3).
| % of childhood immunisation coverage | 1970 | 1980 | 1990 | 2000 | 2010 | 2016/17 |
|---|---|---|---|---|---|---|
| BCG for infants | 46.6 | 88.2 | 97 | 99.3 | 99 | 98.55 |
| DPT (diphtheria, pertussis, tetanus) for infants (3rd dose) | 15.0 | 67.0 | 89.9 | 98.7 | 101.14 | 99.34 |
| Polio for infants (3rd dose) | 15.0 | 72.0 | 89.6 | 93.4 | 94.13 | 99.34 |
| Measles/MMR (measles, mumps, rubella) for infants | 10.0 | 20.0 | 87.1 | 93.9 | 96.1 | 88.8 |
| 1957 | 1970 | 1983 | 1990 | 2000 | 2010 | 2016/17 | |
|---|---|---|---|---|---|---|---|
| Infant mortality rate (per 1,000 live births) | 68.9 | 39.4 | 20.2 | 13.1 | 6 | 6.7 | 7.3 |
| Neonatal mortality rate (per 1,000 live births) | 29.6 | 21.4 | 12.3 | 8.5 | 3.1 | 4.3 | 4.2 |
| Toddler mortality rate (per 1,000 population aged 1–4 years) | 8 | 4.2 | 1.7 | 0.9 | 0.5 | 0.4 | 0.4 |
| Under-5 mortality rate (per 1,000 live births) | 110.4 | 55.9 | 26.6 | 16.8 | 7.9 | 8.5 | 8.6 |
The two programmes that failed to live up to their initial promise were those for TB and malaria. Although greatly reduced during the 1990s, TB incidence remained a problem. There were two contributing factors: first, the large concentration of foreign workers from neighbouring countries were a continual pool of infection. Local surveillance and control systems were ill-prepared to detect and manage them (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). Second, the HIV/AIDS epidemic brought with it an associated increase in TB due to impaired immune systems (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.). The treatment modalities available at that time and programme strategies were inadequate for addressing this threat. For malaria, although incidence declined significantly, pockets of transmission and endemic levels persisted. There were several contributing factors, including people movement that was difficult to monitor, insecticide resistance, drug resistance and changes in vectors.
The role of feedback loops in CDs is well known among epidemiologists. They use stock-and-flow models, such as the susceptible-infectious-recovered (SIR) model, to predict and curb the spread of disease. Successful control of CDs relies on disrupting biological transmission feedback loops via vaccination, quarantine, culling of vectors, etc. The wide acceptance of such models in the health profession provides a useful entry point to many important system dynamics concepts.
6.3 The Next 30 Years: The Era of the Integrated/Horizontal Approach to Disease Control (Mid-1980s to the Present)
6.3.1 The Changing Disease Profile
6.3.1.1 The Rise of Non-communicable Diseases
After the late 1980s, socio-economic development, urban migration, changes in work and lifestyles, and demographic transition to fewer children and more people of working age resulted in an evolving disease profile (see Chapter 3). NCDs such as cardiovascular disease, diabetes mellitus and cancer emerged as major contributors to the disease burdens (Supplementary Table 6.a). There was also a shocking rise in the prevalence of NCD risk factors over the years, as shown in the National Health and Morbidity Surveys (NHMS) (Table 6.4). In 2016, NCDs accounted for 74% of all deaths (World Health Organization, 2018), while NCD-related morbidities and disabilities had increased by 80% between 1990 and 2013 (Ministry of Health Malaysia & Harvard T. H. Chan School of Public Health, 2016).
| NCD risk factor | 1996 (%) | 2006 (%) | 2011 (%) | 2015 (%) |
|---|---|---|---|---|
| Diabetes mellitus | 8.31 | 11.6 | 15.2 | 17.5 |
| Hypertension | 29.91 | 32.2 | 32.7 | 30.3 |
| Hypercholesterolemia | − | 28.2 | 43.9 | 47.7 |
| Overweight | 16.6 | 29.1 | 29.4 | 30.0 |
| Obesity | 4.4 | 14.0 | 15.1 | 17.7 |
| Physical inactivity | − | 43.7 | 35.2 | 33.5 |
| Smoking2 | 24.83 | 21.54 | 23.14 | 22.84 |
| Alcohol (current drinker) | − | 7.4 | 11.6 | 7.7 |
1 Data for population aged ≥30 years.
2 Data for population aged 15 years and above.
3 NHMS II definition: respondent who reported to be smoking at the time of the survey.
4 Centers for Diseases Control and Prevention (CDC) definition: respondent who reported to have smoked ≥100 cigarettes in their lifetime and smoked daily or some days in the past 1 month.
6.3.1.2 Emerging and Re-emerging Infectious Diseases
Since the 1990s, Malaysia has experienced emerging diseases, including HIV infection, dengue, Nipah virus and severe acute respiratory syndrome (SARS), and re-emerging diseases, including resurgent TB and measles, while malaria persisted in endemic areas, perpetually threatening to spread to other areas. (Table 6.5).
| 1990 | 1995 | 2000 | 2005 | 2010 | 2017 | |
|---|---|---|---|---|---|---|
| HIV | 4.30 | 20.30 | 26.97 | 23.42 | 12.89 | 10.33 |
| Dengue fever | 9.54 | 10.68 | 58.93 | 60.71 | 148.73 | 257.6 |
| Dengue haemorrhagic fever | 1.29 | 1.87 | 3.82 | 14.23 | 1.25 | |
| Tuberculosis | 61.2 | 56.93 | 63.29 | 61.20 | 68.25 | 80.78 |
| Measles | 3.17 | 3.16 | 2.83 | 5.39 | 0.26 | 5.28 |
The first case of HIV was detected in 1986, and by 2017, there were a cumulative 115,263 HIV cases (Ministry of Health, 2018a). Initially confined largely to injecting drug users (IDUs), sexual transmission thereof became more prevalent in recent years and has proved a challenge to control measures. First recognised as a public health issue in 1973, dengue incidence has increased tremendously, from 969 cases in 1973 to more than 100,000 cases, with 200 deaths per year, since 2014 (Ministry of Health, 2016).
The factors contributing to the emergence of new diseases or the resurgence of longer-standing diseases are complex and include population movements and lifestyle changes, globalisation and the movement of goods, adaptive mutations in pathogens and vectors, and environmental changes that facilitate or support changes. Table 6.6 shows the illustrative key features of emerging diseases in Malaysia.
Table 6.6 Illustrative examples of the rapid emergence of and varied challenges posed by emerging diseases in Malaysia
| Year | Virus | Location | Relevant features illustrating the complexity of the disease |
|---|---|---|---|
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| Sibu |
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| 1998 |
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| • Previously existing as infection in pigs, the virus adapted to infect humans, causing fever, encephalitis and a high mortality rate of about 40%. Genotyping and epidemiological studies in Malaysia and several neighbouring countries resulted in better understanding of natural reservoirs of the virus family and raised the international alert on potential danger in the future. |
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| Kuala Lumpur |
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| Avian influenza H5N1 |
| • Highly pathogenic virus originating in poultry. Adaptation to infect humans, causing fever; deaths reported in other countries. Outbreaks detected in poultry in Malaysia. Linked to fighting cocks smuggled from neighbouring countries. Rapid and effective control measures prevented the spread to humans. |
The Nipah virus outbreak in 1998–1999, SARS in 2002–2003 and the H1N1 pandemic influenza in 2009 not only posed an increased healthcare burden but also caused social disruptions and economic loss. Up to 40% of cases, or 105 people, with acute encephalitis (out of 265 cases) died during the Nipah virus outbreak (Reference Looi and ChuaLooi & Chua, 2007), while H1N1 caused 77 deaths (out of 12,307 reported cases) in 2009, the majority of whom were children (Reference SamSam, 2015).
Meanwhile, re-emerging diseases such as TB and measles continue to be a public health challenge. TB cases per 100,000 population declined over 30 years from 350 cases to about 60–68 cases but increased to about 84 cases in the subsequent 30-year period (Ministry of Health, 2016). Similarly, despite a strong childhood immunisation programme, measles increased during the 30 years after 1990, from an incidence of 3.1–5.18 per 100,000 population, and one-third of the cases during the recent 2-year period involved children who had never been vaccinated (Ministry of Health, 2016).
6.3.2 Drivers of Change in the Responses to the Disease Profile
6.3.2.1 Health Information Systems
Improved information systems provided information that spurred policy-makers and leaders in the health sector to review and revise national strategies for disease control (see Chapter 10). For example, surveillance systems provided information on emerging and re-emerging CDs. The NHMS provided evidence of the rapid increase and high levels of risk factors and disease prevalence for NCDs, while NCD disease registers provided information on disease trends and disease burdens, early detection and effective control. In some cases, the information also energised social activists to advocate for revised approaches, for example, for HIV/AIDS.
6.3.2.2 International Movements
International movements such as the United Nations’ millennium development goals (MDGs), sustainable development goals (SDGs) and the WHO Framework Convention on Tobacco Control (FCTC, ratified on 16 September 2005) served to focus attention and provide impetus for stronger efforts. For example, in 2005, the Cabinet Committee on AIDS agreed to pilot test a harm reduction programme for HIV prevention among IDUs despite it being incompatible with the country’s zero-tolerance policy on drugs (see Case Study 6.1). In 2018, the Cabinet Committee decided not to reintroduce ‘kiddie pack’ cigarettes (packs of ten) despite the possibility of increasing tax revenue (Bernama, 2018).
International concerns about cross-border transmission of emerging diseases contributed to stronger collaboration and co-ordination between Malaysia, regional and international agencies such as the ASEAN1 and the WHO2, and bilateral co-ordination with neighbours (e.g. the Thailand-Malaysia Border Health Goodwill Committee, the Health Task Force of the Asia-Pacific Economic Cooperation (APEC) group) (Reference Barraclough and PhuaBarraclough & Phua, 2007).
6.3.2.3 Leadership, Governance and Competing Priorities
The examples of cross-sectoral collaboration for NCDs quoted above also provide evidence of the government’s commitment and the influence of leaders from the health sector and of the MoH in shaping policy that transcended several sectors. However, balancing the competing priorities in health with other opportunities for economic growth and development remains a challenge for Malaysia, especially in NCD prevention. Several factors and entities outside of health have considerable influence. For example, food, beverages and tobacco are deemed promising industries for driving growth in the manufacturing sector in the Eleventh Malaysia Plan (2016–20). However, they might not contribute to the promotion of a healthy lifestyle for reducing CDs and NCDs (Economic Planning Unit, 2015). Population health outcomes require multi-actors and sectors to work together to address social, economic and environmental risk factors. There is top-level commitment in the form of a Cabinet-level committee comprised of ministers from various sectors and chaired by the deputy prime minister and several task forces for establishing priorities and developing strategies (Box 6.4).
However, progress in translating the top-level commitment into genuine collaborations across ministries and agencies is slow, especially at implementation level. The MoH faces a continuing challenge to advocate for and create an enabling environment and an integrated approach for implementing multi-sectoral strategic plans. Such plans require the acceptance of roles, responsibilities and incentives for each agency to contribute to disease control efforts as well as for monitoring and evaluation mechanisms to track performance and accountability.
| Communicable diseases | Non-communicable diseases |
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National committee/task force
Laws and regulations
National Strategic Plan (NSP)
| National committee/task force
Laws and regulations
National Strategic Plan (NSP)
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6.3.2.4 Programme Management and Service Delivery
Disease control programmes require considerable structural and functional change to address the changing epidemiologic picture. The previous national control programmes for CDs had tightly knit management structures at MoH level, together with a high level of authority. Hitherto, leadership for managing NCDs had primarily been the purview of various clinical disciplines, such as cardiology, nephrology or oncology. The introduction of a more holistic perspective to NCD control required a more collaborative management structure that allowed inputs from various disciplines and shifted the focus from patient care to population outcomes. This required shared leadership between public health, clinical and laboratory specialist disciplines. Inevitably, the authority structure and interrelationships changed. Also, disciplines that had previously worked within a small circle of related disciplines had to gain competence in collaborating at multi-sector level and aim at population-wide behaviour change, working with communities and using mainstream and social media.
The Epidemiology Unit, previously established under the Health Division of the MoH in 1971, had focused on CDs. It was re-organised in 1992 (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.) to expand its scope to include NCDs, disease surveillance, HIV/AIDS, vector-borne diseases, occupational and environment health and tobacco control, and public health laboratories. Its responsibilities include policies, planning and strategic management, building integrated and collaborative efforts with other agencies including healthcare providers in the private sector, and providing a platform within the MoH to co-ordinate inputs from the various clinical disciplines as well as with the research institutions3 that provide laboratory expertise or programme evaluation and investigative skills.
As discussed in Chapters 4 and 5, since the early 1990s, the service delivery system was re-organised and upgraded with the appropriate technology and staff, particularly at the primary care level, to strengthen comprehensive management of CDs and NCDs. Box 6.5 provides examples of the initiatives. Public sector clinics have standardised clinical management protocols to guide service providers, but the process of placing fully trained multi-disciplinary teams is a slow, ongoing process and far from complete (see Chapter 4). For example, healthcare providers’ insufficient interpersonal and communication skills contributed to gaps in managing diabetic patients (Reference Lim, Aagaard-Hansen, Mustapha and Bjerre-ChristensenLim et al., 2018). Reference ChanChan (2015) highlighted the need for trained diabetic nurse educators to empower patients for self-care. Additionally, efforts at addressing NCD management are hampered by inadequate referral systems, lack of continuity of care between primary, secondary and tertiary care, and inadequate involvement of private general practitioners in the co-ordinated management of NCDs (see Chapters 4 and 5).
Box 6.5 Examples of integration of disease prevention and control activities (prevention, early detection, management and treatment) in PHC clinics
1995: Breast self-examination (BSE) and annual breast examination by trained health workers
1996: Decentralisation and transfer of general outpatient services in hospitals to PHC clinics
1998: HIV screening and management services such as prevention of mother-to-child transmission (PMTCT) programme
2000 onwards: Integration of diabetes screening and management, methadone services for IDUs, management of other NCDs
NCD monitoring evolved from early ad hoc initiatives from various clinical disciplines that established patient registries4 to monitor their disease speciality. This resulted in over 31 separate disease registries by 2012, most of which had resource constraints. There were over 70 databases with no linkages to each other, and data standards varied (Clinical Research Centre, 2012). Efforts to centralise the registries and standardise the quality of data face several challenges, including the lack of resources (workforce, funding and information communication technology (ICT) infrastructure), a governing body and data sharing between registries. The more successful registries are those that deal with single diseases or interventional entities and that require data input from fewer sources. Examples are the renal and cataract registries that contribute to continuous improvement in quality of care.
Recognising the high cost of managing and treating NCDs, the MoH adopted a key strategy of encouraging healthier lifestyles that would reduce NCD risk factors in the community. A series of national healthy lifestyle programmes targeted at the general population (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.) disseminated key messages through a variety of channels. Also, specially designed community mobilisation efforts were implemented to empower communities to foster behaviour change with the involvement of multiple agencies such as the Ministry of Education and the Ministry of Information. Despite these efforts, diabetes, obesity and overweight increased dramatically, and smoking rates remained unchanged (Table 6.4). Malaysia has yet to find effective means of addressing these challenges.
The health system had to respond to emerging and re-emerging CDs with better tools for rapid diagnosis, rapid and effective analysis of epidemiological data and rapid response capability to control outbreaks – this required sophisticated technology at multiple levels: field, laboratory, clinical and digital information. The effort required financial resources and higher levels of competency in human resources. The continuing burden of dengue, malaria and TB required multi-agency collaboration.
Earlier years had seen the development of surveillance and systems to respond to CD outbreaks. The new challenges, illustrated in Table 6.6, resulted in further evolution, and the key milestones in Box 6.6 demonstrate the range of stakeholders and activities involved.
1999: Inter-ministry committee for the control of zoonotic diseases
2002: Epidemic intelligence programme
2006: National influenza pandemic preparedness plan
2007: Crisis preparedness and response centre
2008: Risk communication plan
New procedures required the district health office to act as a gatekeeper to collect data routinely from a wider range of stakeholders, including health facilities in the public and private sectors, such as laboratories, clinics and hospitals (clinical-based surveillance); the Department of Veterinary Services and FOMEMA (Foreign Workers’ Medical Examination); and communities (Ministry of Health, 2004).
Monitoring systems established by the earlier national control programmes for CDs such as TB had been merged into the mainstream by 1995, whereby district health offices were the nodal points for integrating data from hospitals and clinics. Nevertheless, at the national level, separate programme entities maintained some elements of their original structure. For example, the chest clinics maintained their own TB registry, and most of the district health offices had limited access to such data, leading to a lower priority for TB control (Ministry of Health, 2002). The situation only improved in 2002 when the National TB Information System (TBIS) gave the district health office full responsibility for co-ordinating and monitoring the information. Nonetheless, contact tracing for CDs such as TB and HIV remains a concern, particularly among the key populations, that is, migrant and rural populations, including the indigenous populations (Reference Suleiman and JegathesanSuleiman & Jegathesan, n.d.).
The health system has frequently struggled when it has had to change human behaviour for successful disease control. Health promotion often follows a knowledge gap theory, assuming that providing the right information will yield the right behaviour, but with very limited results. Positive feedback from unhealthy behaviour – for example, the satisfaction from eating unhealthy foods – is often immediate, whereas negative feedback – for example, cardiovascular disease – is distant, vague and uncertain. More immediate feedback that promotes healthy behaviour and discourages unhealthy behaviour, such as social approval, may provide useful tools for individual behavioural change. On a larger scale, we need to consider what types of feedback loops will create health-promoting environments.
6.4 Conclusion
Malaysia has successfully reduced the burden of several CDs through time-limited dedicated programmes aimed at specific diseases. These programmes largely avoided the well-known disadvantages of vertical programme approaches. There are several contributing factors: programme designs recognised and relied on the existing and developing healthcare delivery system. Thus, at the front line, service delivery was in the hands of the PHC providers.5 This avoided unnecessary duplication and inefficiencies and subsequent potential redundancy and wastage of human resources and physical facilities. On the other hand, the dedicated vertical approach enabled the development of competencies in programme management, supervision, monitoring and evaluation that later transferred to the public health sector. Conceivably, reliance on domestic and not foreign funding ensured that programme design was accountable to domestic authorities and therefore aligned to national health and development priorities and strategies. (Other chapters elaborate on these priorities and strategies.)
Emerging and re-emerging infectious diseases pose continuing challenges, some of which have been easier to address. The underlying factors are the adaptive behaviour of pathogens, changes in the habits and immune levels of communities that expose them to virulent pathogens, and changes in the environment that facilitate change in either pathogens or humans. There is insufficient knowledge on how the emergence of a new disease can be prevented. Therefore, health systems rely on rapid recognition and effective control of outbreaks. Quick to recognise that Malaysia has the climatic and geographic features that place it at risk of emerging diseases, particularly those arising from zoonotic pools of infection (Ministry of Health, 2002; 2004), the country rapidly developed the capacity for early recognition and containment of outbreaks (Reference LimLim, 1999). There has been less success in dealing with re-emerging diseases caused by human behaviour such as migration and drug use or by the adaptive behaviour of pathogens and vectors compounded by human behaviour, such as antibiotic-resistant microbes and dengue.
Malaysia has had less success in the field of NCDs. The reasons for this are unclear. The range of diseases is much broader and their causative and contributory factors more varied. For some, such as several neoplastic diseases, medical knowledge about their prevention and management is limited. For others, such as cardiovascular and metabolic diseases, the contributory factors require a change in human behaviour, which is complex and dependent on a wide variety of influences. The health sector has yet to devise effective means of addressing many of those influences.
6.5 Key Messages from Malaysia’s Experience
6.5.1 What Went Well?
The design of disease-specific control programmes, as far as possible, used existing healthcare delivery systems. They also developed specific competencies in programme management, supervision, monitoring and evaluation, which later transferred to the public health delivery system.
The health system rapidly developed the capacity for prompt recognition and effective control of outbreaks of new diseases, as knowledge on prevention was insufficient.
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