Article: Risso-Gill, I., Balabanova, D., Majid, F., Ng, K. K., Yusoff, K., Mustapha, F.,… & McKee, M. (2015). Understanding the modifiable health systems barriers to hypertension management in Malaysia: a multi-method health systems appraisal approach. BMC Health Services Research,15(1), 254
Background: The growing burden of non-communicable diseases in middle-income countries demands models of care that are appropriate to local contexts and acceptable to patients in order to be effective. We describe a multimethod health system appraisal to inform the design of an intervention that will be used in a cluster randomised controlled trial to improve hypertension control in Malaysia.
Methods: A health systems appraisal was undertaken in the capital, Kuala Lumpur, and poorer-resourced rural sites in Peninsular Malaysia and Sabah. Building on two systematic reviews of barriers to hypertension control, a conceptual framework was developed that guided analysis of survey data, documentary review and semi-structured interviews with key informants, health professionals and patients. The analysis followed the patients as they move through the health system, exploring the main modifiable system-level barriers to effective hypertension management, and seeking to explain obstacles to improved access and health outcomes.
Results: The study highlighted the need for the proposed intervention to take account of how Malaysian patients seek treatment in both the public and private sectors, and from western and various traditional practitioners, with many patients choosing to seek care across different services. Patients typically choose private care if they can afford to, while others attend heavily subsidised public clinics. Public hypertension clinics are often overwhelmed by numbers of patients attending, so health workers have little time to engage effectively with patients. Treatment adherence is poor, with a widespread belief, stemming from concepts of traditional medicine, that hypertension is a transient disturbance rather than a permanent asymptomatic condition. Drug supplies can be erratic in rural areas. Hypertension awareness and education material are limited, and what exist are poorly developed and ineffective.
Conclusion: Despite having a relatively well funded health system offering good access to care, Malaysia’s health system still has significant barriers to effective hypertension management.
Discussion: The study uncovered major patient-related barriers to the detection and control of hypertension which will have an impact on the design and implementation of any hypertension intervention. Appropriate models of care must take account of the patient modifiable health systems barriers if they are to have any realistic chance of success; these findings are relevant to many countries seeking to effectively control hypertension despite resource constraints.
With the rise of non-communicable diseases (NCDs) in many low and middle income countries, equitable, effective, appropriate and efficient models of care and service delivery are required.
This paper seeks to understand the barriers and facilitating factors for optimizing hypertension management in Malaysia through a patient-centred lens. A health systems analysis approach was taken using hypertension as a tracer to understand the interacting parts of the health system. Using literature review and key informant interviews with providers and patients, the authors described modifiable system-level barriers as patients with hypertension moved from lifestyle to diagnosis to pharmacological treatment to follow up.
Despite the fact that access to medicines was not a reported problem by key informants, other related health system factors affected appropriate use and prescribing practices. For example, researchers found that pharmacists are not always present in facilities, and that lack of affordable transport is a significant barrier to patients accessing clinics, which means they may not be willing to go to clinics to refill their prescriptions. In the context studied, the overlap between the private and public sectors had important implications for use of medicines. For example, the concomitant use of the private and public sectors has led to incomplete patient records and lack of formal follow up which makes it difficult to track prescriptions. Information technology systems are recommended to address this barrier. Another big barrier to appropriate use of and adherence to medicines, as understood by key informant interviews, are gaps in patient education. As antihypertensive medicines do not have clear signs of positive effect, interruptions in treatment and non-adherence happen often. Furthermore, the three belief systems in this context play a role in the type of medicines patients trust. Traditional Chinese, Ayurvedic and Malay medicines are seen as more acceptable (more natural and more halal) and their use is often not disclosed to doctors.
This study demonstrates the importance of taking stock of the health system landscape in a specific context in order to understand why medicines may not be having their intended effects despite an effective delivery system. In Malaysia, 80% of products are locally manufactured which has had cost-saving effects, and key informants do not identify access to medicines as a problem. However, there are a lack of patient education on needed treatment of asymptomatic conditions and the importance of following medication regimens, as well as the need to disclose use of traditional medicines to avoid potential adverse effects. A harmonized health promotion approach across the different cadres of health workers is required to ensure that consistent messages are repeated to patients throughout the health system to ensure appropriate use and adherence to medication regimens.
This commentary features in the upcoming Medicines in Health Systems Quarterly newsletter.