Consequent to rapidly declining mortality and birth rates, developing countries, including Malaysia, can expect a rapid increase in the population aged 60 years and above. The health of the elderly is intimately tied up with both biophysical as well as psychosocial factors which include status loss, loneliness, fear of illness and death, poverty, harmful life-styles and deterioration of the quality of life. The effects of these psychosocial factors can manifest as sleep difficulties, worry and anxiety, depression, loss of interest, and a feeling of tiredness. In extreme cases, there may be auditory or visual hallucinations or paranoia. In the present paper, which is based upon a WHO sponsored study of 1001 elderly Malaysians, it is noted that 36% of the elderly have sleep difficulties, 47% "feel tired", 31% have a "loss of interest" and 22% are "worried tense". However 71% of the elderly are able to correctly perform at least 12 of 15 cognitive tests. 20% of elderly men smoke 15 or more cigarettes a day while 44% smoke at least one cigarette a day. 40% of elderly men indicate that their families complain about the amount of alcohol they drink. Undoubtedly primary health care programmes need to be re-oriented to the problems and needs of the elderly in countries such as Malaysia.
In 1984, in Sarawak, there were a total of 1,099 recorded cases of leprosy for a population of 1.3 million. However, for each case recorded, it is estimated that two others remain undiagnosed as a consequence of the stigmatization associated with leprosy. For the five year period, 1979-1983, an average of 29 new cases were detected each year of which 8.6 (30%) were deformed due to the late stages at which it was being reported. To increase the case-finding rate, human behavioural research was applied to the leprosy control programme so as to develop culture-specific health education packages aimed at self diagnosis and self referral in order to detect the large pool of undiagnosed cases hidden behind the veil of aversion, fear and ignorance. This was achieved through anthropological studies to identify how the various major ethnic groups perceived leprosy and their attitudes towards leprosy. Taking into account these findings, health education packages aimed at adults as well as children were developed for the Chinese as well as the non-Chinese, and consisted of newspaper articles, cartoon tape-slides, cartoon story books and posters.
The definition of primary health care is basically the same, but the wide variety of concepts as to the form and type of worker required is largely due to variations in economic, demographic, socio-cultural and political factors. Whatever form it takes, in many parts of the developing world, it is increasingly clear that primary health care must be provided by non-physicians. The reasons for this trend are compelling, yet it is surprisingly opposed by the medical profession in many a developing country. Nonetheless, numerous field trials are being conducted in a variety of situations in several countries around the world. Non-physician primary health care workers vary from medical assistants and nurse practitioners to aide-level workers called village mobilizers, village volunteers, village aides and a variety of other names. The functions, limitations and training of such workers will need to be defined, so that an optimal combination of skills, knowledge and attitudes best suited to produce the desired effect on local health problems may be attained. The supervision of such workers by the physician and other health professionals will need to be developed in the spirit of the health team. An example of the use of non-physicians in providing primary health care in Sarawak is outlined.
Domiciliary deliveries have always been the responsibility of traditional birth attendants. Since Independence, acquired in 1957, educated young women have been trained as auxiliary midwives and sent to serve in rural communities where they usually are met with resistance by the established traditional birth attendants. To counter this and to incorporate the traditional birth attendants into the health team, new roles were developed for each so that the two would be able to cooperate and support each other rather than rival and antagonise each other. A specific experience in one area of Malaysia is examined as an example.
One hundred and ninety-nine children brought by 181 adults to a child health clinic based in a rural health sub-centre in Peninsular Malaysia are studied. It is noted that the families from which they come are relatively poor, with a large number of children, and that they are fairly highly motivated. Forty-four per cent of children attending the clinic at the time of the study are symptomatic indicating the need to organise the child health clinic on a "preventive-curative" basis. It is also noted that the young child is initially seen in early infancy but is lost to the clinic when he is older making it judicious to formulate immunization schedules that take this into account.
Since Independence, gained in 1957, major changes have occurred in the rural areas of Malaysia not least amongst which has been the provision of maternal and child care services to hitherto neglected areas. In the first part of this paper, the demographic and disease patterns are described. The second part outlines the general development efforts and describes in greater detail the rural health services that have been organized in Malaysia. In the concluding section, changes in mortality and morbidity are examined.