Participants
During an MOH-organized 3-day workshop session on revising the FDC guidelines, we approached a total of 30 people, all of whom agreed to participate in this research. However, 10 withdrew after receiving the question list because they were not confident about being interviewed, and four were too busy, leaving a final 16 participants. Thus, the interviewees, to a certain extent, are experts in the field and have better knowledge than most stakeholders. The majority of the participants were also involved in FDC pilot projects at national or state level. Table 2 shows the classification of the 16 participants, among whom were federal-level policymakers in the capacity as director, deputy director, or SPAD. The state-level implementers were SPADs, who were also PHP or MOs; at the primary clinic level, the interviewees were FMS and MOIC.
Table 2
Classification of participants involved in the study
Participants
|
Gender
|
Involvement in FDC pilot project
|
Years on involvement in FDC
|
Years of service in the MOH
|
Policymakers at the Federal Level
|
|
Policymaker 1
|
Female
|
Yes
|
3
|
28
|
Policymaker 2
|
Female
|
Yes
|
5
|
25
|
Policymaker 3
|
Female
|
Yes
|
5
|
12
|
Senior Principal Assistant Director (SPAD) at the State Level
|
|
Senior Principal Assistant Director 1
|
Female
|
No
|
3
|
15
|
Senior Principal Assistant Director 2
|
Female
|
No
|
2
|
16
|
Senior Principal Assistant Director 3
|
Male
|
No
|
2
|
9
|
Family Medicine Specialists (FMS) at the Primary Care Clinic Level
|
|
Family Medicine Specialist 1
|
Female
|
Yes
|
5
|
25
|
Family Medicine Specialist 2
|
Male
|
Yes
|
5
|
18
|
Family Medicine Specialist 3
|
Female
|
No
|
2
|
30
|
Family Medicine Specialist 4
|
Female
|
Yes
|
5
|
20
|
Family Medicine Specialist 5
|
Female
|
Yes
|
3
|
18
|
Family Medicine Specialist 6
|
Female
|
Yes
|
3
|
22
|
Family Medicine Specialist 7
|
Female
|
Yes
|
3
|
17
|
Family Medicine Specialist 8
|
Male
|
Yes
|
3
|
25
|
Medical Officers-In-Charge (MOIC) of Primary Care Clinics
|
|
Medical Officer 1
|
Male
|
Yes
|
4
|
11
|
Medical Officer 2
|
Male
|
Yes
|
4
|
13
|
Interviews and analysis of transcripts
Semi-structured interviews were conducted over 3 months from November 2019 to January 2020. All interviews were conducted in person in locations where the participants were at ease. Two interviews were conducted entirely in English, while the remainder were a mix of English and Bahasa Malaysia. On average, the interviews spanned around 30 minutes to 1 hour. The interviews were coded to cover all themes developed sufficiently from the topics, and the 15 themes were grouped to fit the topics (Fig. 2).
Topic 1: The objectives of the FDC
From the interviews, all participants agreed that the FDC is a healthcare service delivery system approach in public primary care settings that emphasizes the delivery of integrated, personalized, family-centered, and comprehensive care to clients. It is a new approach unique to the Malaysian setting, in which primary care services in public clinics are fragmented and segmented. The fragmentation is due to healthcare workers from various disciplines, such as doctors, nurses, medical assistants, nutritionists, physiotherapists, and pharmacists, being poorly coordinated and working independently with the clients. Primary care services are also segmented in that there are three main units in the clinic: outpatient, chronic NCD, and maternal and child health (MCH). The NCD unit caters to clients specifically with diabetes and HPT, while the MCH unit caters to pregnant women and to children aged < 5 years. The outpatient unit manages all other clients, such as those with fever, flu, and all other problems. The situation of clients receiving services in the clinic was best described by one participant:
“The mother who is pregnant will be seen at the maternal and child health unit; the child who is probably 3 to 4 years old also will be seen by the same unit. However, the child who is 7 or 8 or 9 years old or the husband will have to be seen in the outpatient unit. So, it becomes difficult for doctors to deliver patient-centered and family-centered care to their clients. It becomes much more difficult for the patients because they have to take separate numbers for the different units to see different doctors. It will also increase the waiting time for the clients.”(Policymaker 2)
Thus, at the primary care clinic level, the objective of the FDC is to create a system that allows healthcare workers, especially doctors, to deliver integrated, personalized, family-centered, and comprehensive care to clients. In this system, doctors will be able to see clients and their family members as a whole without segmentation.
However, the participants mentioned several FDC objectives at a more macro level and for the longer term. At meso-level and intermediate-term, the objective of the FDC is for healthcare workers in the clinic to be able to map the burden of diseases in the population under the clinic’s operational area based on the client data available at the clinic. This strategy can assist health services delivery planning through a targeted approach, in which health programs are conducted based on the population’s disease burden. One participant explained that the clinic’s operational area is divided into zones to achieve this targeted approach.
“Actually, with the formation of zones, our strategies are becoming more focused based on my experience. Subsequently, when we analyze the data, we should be able to identify diseases more prevalent in a particular zone. So, whatever health education programs or interventions can be planned based on the mapping. For example, a particular zone was found to have more issues related to the elderly population. So, we can plan programs related to the elderly population in that area.”(FMS 2)
At macro-level and the long-term, the FDC is aimed at increasing the accessibility of healthcare services to the population and thus improve UHC. This objective can be achieved when the whole population in the clinic’s operational area is registered to a healthcare facility. Thus, individuals in the population who are not registered to either public or private clinics can be identified and encouraged to visit the clinic for a medical check-up. There is also a need to prepare the clinic for more complete healthcare reform, especially from the financing aspect.
“Then, there has been a discussion on healthcare financing initiatives that have been going on and on. But, every time any initiative came, we feel that every person must be registered first. Every individual in the population must be registered. So, either they are registered with the GP, or they registered with the.. aa.. public clinic” (Policymaker 1)
Topic 2: The initiatives of the FDC
All participants agreed that the initiatives of the FDC must be linked to the objectives. The majority of FMS and MOIC mentioned that adjusting client flow was the first step in ensuring integrated, personalized, and family-centered care.
“The first step I have to study the patient’s flow in the clinic. So, the first three months every morning, I will be standing at the front counter to have a look at the types of patients coming, their numbers as well as the defaulters.”(FMS 1)
However, this initiative may confuse the clinic-level implementers because the client’s pathway is not well defined in the guideline or by the policymakers. Some of the stakeholders learned to adjust the client flow based on visits to the pilot clinics and tried to adapt them with guidance from the state-level implementers. In contrast, the pilot clinics experimented with their client flow and made adjustments several times to suit their infrastructure and resource availability. After that, the flow was improvised based on client and staff feedback. This is why variation in client pathways is unavoidable in the implementation process. The policymakers considered any variation acceptable as long as it did not deviate from the concept. One policymaker lamented that some of the implementers strove very hard to have the same clients seen by the same doctors every time, which is impossible in the current setting. Furthermore, it imposed more resource constraints on the already resource-deprived clinic.
“At first, we only knew the theory. When it was piloted at our clinic, we can do anything. We did outreach for the population registry at the initial stage because we were able to do so. So, when we presented the outcome, they found this may be the best formula. That was why FDC was continued until now.” (FMS 2)
The formation of teams of doctors in a clinic is indispensable for the FDC, ensuring continuity of care. Ideally, in many countries, a family is assigned to a particular GP to receive primary care services. However, in Malaysia, it is impossible to do so due to the lack of human resources in the public sector. At the same time, those in the private sector work separately under a different system. The best that the public healthcare system can offer is to have one family seen by the same team of doctors at each clinic visit. It is assumed that doctors on the same team are in constant communication with each other to manage their clients.
“To have a system whereby a family is assigned to a doctor or a general practitioner is ideal but no practical. Due to the limited resources in our public clinic, a team’s formation can ensure continuity of care to the patients and their family members. They will be seen only by the same team of doctors. This system might work if the team strives to achieve the same goals and have standardized management of patients.” (FMS 3)
Consequently, the formation of teams of doctors gives rise to the formation of zones and hence, the practice of zoning of the other healthcare professionals in the clinic. The team is now termed the multi-disciplinary team or family health team (FHT). The formation of this team aids the allocation of health programs as well as for monitoring performance.
“I told them that let’s zone all the staff. So, all the staff will be zoned, including the medical assistants, pharmacists, lab technicians and everyone. Why I zoned them? I zoned them is basically to help out in the running of campaigns. So, it is easier for me to allocate when they do outreach for registering the population.” (FMS 4)
“In my district, we present the clinic’s performance according to zones in FDC. For example, zone A, B, C and D. So, it is not like the ordinary performance presentation because we go into the details. We identify the problematic zones. For example, zones in which the HBA1c of diabetic patients were not too good.”(FMS 2)
When the initiatives mentioned were already in place, it was assumed that the development of the population registry would become easier based on the division of labor. The policymakers knew that it would be impossible to register the whole population under the clinic’s operational area. So, the best alternative would be to divide the population into zones, and each team in charge of the zone would begin registering clients in phases. Nevertheless, there were problems of information-sharing between the zones to create a broader picture of the whole population in the process.
“If they have other alternatives, then why not? However, what alternatives do they have now in terms of the feasibility of doing it? So, it is just like you and me handling a big project. It only makes sense when I take a part of it, and you take another part. But, we must put back the parts together and share. It is probably the best option they have. However, they may have forgotten once they have divided themselves. They forgot to put back together.” (Policymaker 1)
Topic 3: The resources required for implementing the FDC
Most stakeholders believed that assistance in the form of human resources, equipment, and upgrading the physical infrastructure would facilitate FDC implementation in the clinic. For example, the staff of one clinic were happy with the FDC because they had suitable infrastructure, but requested additional human resources. The needs are even more pressing in densely populated areas such as Selangor and Kuala Lumpur, where public primary care clinics cannot keep up with the population growth.
“If we were given more staff, then the infrastructure must be able to accommodate them. For example, even if we were given extra staff for consultation or registering the population, we do not have enough space to put them. The equipment also includes computers to register all that.” (SPAD 1)
However, it does not mean that the FDC cannot be implemented successfully without material assistance. Currently, other than the pilot clinics at national level, the other clinics are expected to use existing resources for the implementation, with some modifications. One participant mentioned that the FDC is a system and thus does not require many resources.
“No extra resources. We were using existing resources all the while. For me, the best if we can get all the assistance, but it does not mean that without assistance, we cannot do it. For me, I have to work only with my clinic’s staff. But actually, the resources are there, but the system is not in place. That’s all.” (FMS 1)
Moreover, the policymakers explained that they did not intend to duplicate services. For example, there is no need to have three separate injection rooms, three ultrasound machines, or three registration counters in the presence of three teams or zones; they can share the same space and equipment. Thus, generally, the need for extra resources in implementing the FDC is minimal. The FDC is not meant to create clinics within a clinic, as understood by some of the implementers.
All stakeholders also highlighted the most labor-intensive activity in implementing the FDC: entering the client or population data into the system. It is especially frustrating when the MOH continually changes the data entry system to be used, and all such systems are unstable. There have been instances when staff were required to enter data from the same client several times because it disappears from the database. Even if a stable system were available, the MOH is always developing a new IT system in which data migration from the previous system is not possible.
“Actually, our staff in the clinic are very good. Although the resources are limited, they still do the population registry. But if I’m going to start fresh, I want the MOH to confirm the system first. That is the challenge. In terms of resources, who will enter the data?” (FMS 3)
“Even though there is a stable system mentioned by Dr. N, I’m a bit worried when he wanted to introduce it to the clinics. What happened when we have already entered all the data into his system, and suddenly, the clinics were asked to use a new IT system, Tele-Primary Care Oral Health Clinical Information System (TPC OHCIS)? Who wants to be responsible when the data cannot be transferred, and they have to enter the data again?”(SPAD 2)
Nevertheless, all clinic stakeholders agreed that staff and clients are the essential assets in FDC implementation. Their involvement is crucial because the FDC is a change to the system that has existed for many years in the clinic. Thus, regular staff engagement involving various disciplines in the form of serial meetings can help them understand the FDC and support the initiative. Without their support and commitment, FDC implementation will fail from the very beginning. For this purpose, a clear and standardized guideline may be helpful. For example, doctors in particular need to invest a significant amount of time for training in client integrated management. This training is required because some doctors may not be very well equipped to manage some types of patients due to service segmentation. Equally, educating clients on the new system is essential for avoiding complaints. Most pilot clinics experienced this at the initial stage, but the complaints subsequently turned into compliments.
“So, the first step is for trying to make sure everybody is on the same level of understanding and try to make a better guideline in term of better implementation at the ground.” (Policymaker 3)
“We appreciate FDC a lot because everybody is multitasking, and it is good not only for us in the clinic but actually good for them as well. And the teamwork. Definitely, there is much unity in terms of teamwork. Of course, everybody is not happy at the initial stages because they take time to get adjusted. However, after a year or two, the majority of them are happy with FDC.” (FMS 4)
Topic 4: The expected outcomes of FDC implementation
The expected outcomes were divided into short-, intermediate-, and long-term outcomes. The short-term outcomes usually take 1 or 2 years to achieve, while the intermediate-term outcomes may take 3–5 years. Meanwhile, the long-term outcomes may take > 5 years. Some participants believed that implementing the FDC would reduce client waiting times for receiving healthcare services in the clinic in the short-term. As mentioned earlier, the integrated system, where doctors see clients together as a family, contributes to the reduction in waiting time. The other contributing factor is the enhancement in care continuity, resulting in a better patient–doctor relationship. The consultation time can be shortened when the doctor already knows the client’s history or past problems. Moreover, a good patient–doctor relationship is expected to reduce mismanagement and medication errors, reduce appointment defaulters, and increase health screening.
“The first is we can create a good relationship between the doctor and the patient. Secondly, we can reduce the waiting time because when the doctor does not know the patient, they will take a longer time to read the clinic’s card and identify the problems. So, when the doctor knows the patient, they already knew the blood pressure and sugar patterns all this while. So, straight away, the doctor can initiate appropriate treatment. It can also reduce mismanagement and medication errors especially when patients have allergies to a particular medication”(SPAD 2)
For the intermediate-term outcomes, most clinicians suggested that the FDC can improve clinical outcomes. They frequently mentioned the improvement in the HbA1c levels of diabetic patients and better control of blood pressure in patients with HPT. In terms of MCH, they also discussed certain improvements in national indicators such as anemia in pregnancy, high-risk pregnancy, and under-5 mortality. However, measuring these outcomes is possible only if the clinic’s data analysis is performed and divided according to zones. All of the pilot clinics performed this step so that they could compare the performance between zones. Thus, the staff from each zone will have ownership of their clients and are held accountable for their management.
“We have to compare between the zones. We have five zones. A, B, C, D and E. Then, the full mark we give is 5. If zone A is the better one depending on the FDC core team, we give a full mark. The idea is that we want them to be competitive. We want them actually to have ownership and accountability. This method can also be a tool to monitor performance.”(FMS 2)
For the long-term outcomes, the FDC can increase accessibility to healthcare services. For example, the development of a population registry should help healthcare providers identify individuals at risk who are never in contact with the healthcare system. Such individuals should be encouraged to seek treatment early, and nearby primary care clinics will be assigned to care for them. All stakeholders expressed their disappointment when the FDC was used as an excuse to deny services to clients or to refuse clients from other zones. In general, active screening, early treatment, and optimum quality of care can reduce the morbidity and mortality caused by illnesses, especially NCDs.
“FDC approach is to register the population. The registering of the population is not merely going from house to house to get their names, but it means to say to them in a welcoming way: “Please come to our clinic, we are registering you. We want to tell you that you are in zone B. Anytime you come to the clinic, there are these doctors with you. They are in this team.” (Policymaker 2)
Table 3 shows the relationship between the objectives, initiatives, resources, and expected outcomes of the FDC.
Table 3
The relationship between the objectives, initiatives, resources and the expected outcomes of FDC
Resources
|
Objectives
|
Initiatives
|
Expected outcomes
|
1. A clear and standardized guideline.
2. Staff time and training.
3. Clients’ education.
4. Infrastructure.
5. Equipment.
6. Manpower.
7. A stable registration system.
|
Micro-level
1. To create a system allowing the healthcare workers, especially the doctors, to deliver integrated, personalized, family-centered and comprehensive care to the clients.
|
1. Adjustment of clients’ flow in the clinic so that doctors can provide integrated management to them.
|
Short-term:
1. Reduce waiting time.
2. Improvement in the client-doctor relationship.
3. Reduce mismanagement and medication errors.
4. Reduce appointment defaulters.
5. Increase in health screening.
Intermediate-term
1. Better control of hba1c in diabetes.
2. Better blood pressure control of hypertension.
3. Reduction in anemia in pregnancy, under-five mortality and high-risk pregnancy.
Long-term
1. Improve the accessibility of healthcare services in the population.
2. Reduce the overall mortality and morbidity due to illnesses, especially NCDs.
|
Meso-level
2. To map the burden of diseases of the population under the clinic’s operational area based on the clients’ data available in the clinic.
|
2. The formation of a multi-disciplinary healthcare team consisting of doctors, nurses, medical assistants and staff from other services.
3. The analysis of data and performance appraisal according to the teams or zones.
|
Macro-level
3. To increase the accessibility of healthcare services to the population and improve universal health coverage (UHC).
|
4. The development of the population registry for individuals under the clinic’s operational area.
|