CHUM KOK WAI
CHILD HEALTH IN MALAYSIA
INTRODUCTION
Malaysia is one of the countries situated in South East Asia. As a developing country, Malaysia has health problems of both underdeveloped and developed countries. The main provider of health care in the country is the Ministry of Health through its extensive network of health centres, rural clinics, urban polyclinics, maternal and child health clinics, and district and general hospitals. Private hospitals currently account for about 15% of the total number of beds.
DEMOGRAPHY and HEALTH STATISTICS
The population of Malaysia in 1993 was 19 million, most of whom live in rural areas. About 46% of the population was below the age of 20 years. For the peninsular of Malaysia, the crude birth rate for the same year was 27.1 per 1000 and the toddler mortality rate, 0.9 per 1000. The infant mortality rate had fallen from 19.5 in 1982 to 10.6 in 1993. These data indicate that health care in Malaysia is among the best of the developing countries. This is partly attributed to the improved social, economic and environmental standards of the country. The budget for health has increased steadily over the years and in 1993 was valued about $2534 million (Malaysian Ringgit); this was 5.74% of the national budget.
CONTINUING HEALTH PROBLEMS
Communicable diseases still remain a major problem in Malaysia. The three commonest are cholera, typhoid and hepatitis. Meningitis still carries a high mortality of about 20% and contributes to approximately 2% of the paediatric admissions. Rheumatic heart disease constitutes 11.2% of paediatric cardiology cases.
Malnutrition continues to be prevalent in Malaysian children. A survey in an urban squatter population revealed the percentage of underweight children to be as high as 18.9%. In Kelantan (which is one of the poorest of the 13 states in Malaysia) today, 28.5% of the children below five years of age are underweight.
EMERGING HEALTH PROBLEMS
The first HIV-positive case was reported in mid 1986 and up to August 1993, the number of the people who had been infected was 7,496; this included seven children, two of whom were haemophiliacs. A study on gonococcal ophthalmia neonatorum has shown an increase in the percentage of cases infected with penicillin-resistant strains of Neisseria gonorrhoae from 6.4% to 25.9%.
Cases of chloroquine-resistant malaria have been reported in the aborigines in Peninsular Malaysia. Dengue, another vector borne disease that affects mainly children in epidemics, is transforming its clinical pattern into a more severe disease with encephalopathy, renal failure and fulminant hepatopathy.
The overall admission for acute asthma in Malaysian hospitals for 1992 was 20135 compared with 18947 in 1985. It is believed that as many as 15% of Malaysian children might be asthmatic.
NEW MORBIDITY OF SOCIAL CHANGES
Non-accidental injury in this country was first reported in 1974 but was only widely publicized in 1985. In 1987, 147 cases were reported nationwide and in 1991, a tremendous jump to 970 occurred. The Child Protection Act was introduced in 1991, making it mandatory for medical practitioners to report child abuse to a legislated child protector.
There has also been increasing numbers of children involved in road traffic accidents. Their fatality rate has increased from 66 per 100,000 in 1986 to 76 per 100,000 in 1989. Six percent of cases of drug abuse in this country were reported to be in the age range 19 and below.
FOCUS ON PREVENTION
Primary immunization programmes in Malaysia are focused on diphtheria, pertussis and tetanus (DPT), poliomyelitis, tuberculosis and measles. Hepatitis B immunization has been incorporated into the Malaysian extended programme of immunization in 1991. School going children are also offered rubella immunization. The average coverage for three DPT and poliomyelitis immunizations is about 90.8% of live births. BCG given soon after birth has the best immunization coverage of around 98%. However, childhood tuberculosis has still not been eradicated; 316 cases were reported in 1991.
The only nationwide neonatal screening programme currently available in this country is glucose-6-phosphate dehydrogenase (G6PD) screening. In 1993, 2.42% of live births were found to have G6PD deficiency and 86 cases of kernicterus were reported.
QUALITY/INEQUALITY OF CARE
Given the unequal distribution of wealth among the states, difficulties of communications and differing terrain, however, it is not surprising that better facilities are more readily available in the larger cities. For example, the doctor to population ratio in the Federal Territory (Kuala Lumpur) is 1:586 compared with 1:4692 in Sabah (one of the states in East Malaysia). This disparity is mainly due to the preference of private doctors to work in private hospitals or clinics in larger cities such as Kuala Lumpur.
The Paediatric Institute in Kuala Lumpur, which officially opened in 1992, is the only children's hospital in Malaysia and provides paediatric subspecialty services and serves as the ultimate referral centre for the whole country. This service is supplemented by paediatric departments in the main general hospitals in each state and some of the larger district hospitals.
MANPOWER AND TRAINING
In 1992, there were only 48 paediatricians in the Ministry of Health hospitals whereas about double this number were working in private practice and n teaching hospitals. The target requirement for paediatricians in the Ministry of Health by the year 2000 is estimated to be 227 to provide optimal service in general and district hospitals. This figure is based on the estimated need of one paediatrician for every 2500 children. To achieve this objective, the government has introduced a local four-year postgraduate training programme in the three local universities. Some 40 paediatricians have already graduated from these courses since their introduction in 1984. At the same time, a significant number of doctors became paediatricians the 'traditional' way - that is , by doing the British MRCP examinations.
OTHER SHORTCOMINGS
National data collection remains a big problem in Malaysia. Mortality statistics may not be accurate as not all causes of death are medically certified. In 1993 only 42% of deaths were certified, most of these were not confirmed by post-mortem examination because consent is usually not forthcoming.
Statistics indicated that about 20% of infant deaths are due to congenital abnormalities but a service for chromosomal analysis is not easily available. Sophisticated antenatal diagnostic services are also not developed because of the objection to therapeutic abortion.
Immunization coverage, although among the highest in developing countries, is still not fully satisfactory. The emergence of certain religious groups that do not believe in immunization and the increasing immigrant population are likely to pose problems in eradicating communicable diseases.
There is much room for improvement in the management of disabled children. Expensive treatment of chronic diseases is not easily available. For example, at one of the best paediatric centres, only about 25% of children with thalassemia major receive iron chelation treatment. It is fortunate that a disease like cystic fibrosis is non-prevalent in this country otherwise it would put great demand on resources.
