Health profiles of foreigners attending primary care clinics in Malaysia

Foreigners accounted for 7.7 % of all primary care consultations and most encounters were from private clinics. This was expected as some foreign workers have access to private clinics through company panel clinics or some may find easy access to private clinics with shorter waiting time and longer operating hours which run beyond office hours and on weekends [36] as was found among migrant workers in Thailand [37]. There were differences in the type of illnesses encountered in public and private clinics; commonest conditions sought in public clinics among foreigners were obstetric cases (37.7 %) and chronic diseases (15.5 %) whereas health problems encountered in private clinics were mostly minor conditions or acute illnesses. This is similar to findings previously observed in studies of general patient population in Malaysia where public clinics in general handled more chronic diseases while private clinics saw more cases of acute and minor ailments [38, 39].

We found that obstetric cases were frequently encountered, particularly in public clinics where nearly half of the encounters are related to pregnancy. The preferences for government healthcare facilities over private sector for obstetric problems is similar to the findings from the study of migrant workers in Thailand [37]. The preponderance of pregnancy-related cases in public clinics might be related to cost, as private healthcare charges are fee-for-service. Although most foreigners take up insurance coverage on entering the country, most often it does not cover care related to pregnancy. This finding highlights the prevalence of obstetric cases and suggest the need for maternal health services among foreigners. This is in line with a previous study conducted in Sabah – a state in Malaysia with the highest number of foreigners’ population, which reported that the use of antenatal care services among foreigners during pregnancy was fairly high (91.0 %), although the proportion of those who did not obtain antenatal care was also significantly higher (8.1 %) when compared to Malaysian citizens (2.9 %) [40]. Studies also showed that foreign migrants tend to initiate care at a later stage of pregnancy and this could be attributed to unfamiliarity with the health system or inadequate access to healthcare facilities [9, 40‐42]. All pregnant women should have access to adequate antenatal care as appropriate management could reduce maternal mortality rates and birth complications [43]. It is also interesting to know which category of foreigners these pregnant women fall into considering that pregnancy is one of the conditions that precludes employment of a foreigner in the non-professional category of work and these blue collar workers are not allowed to bring their family members to live in this country during the term of employment [22]. Our study however, did not collect details on their socioeconomic or occupational status hence this could not be determined.

Beside obstetric cases, our study found that chronic non-communicable diseases, namely hypertension, diabetes mellitus and lipid disorder were frequently encountered in public clinics as they amounted to 15.5 % of the diagnoses. While these conditions were also managed in private clinics, the percentage was smaller at 4.5 % because private clinics had more cases of acute minor ailments. A study by Leong in 2006 which reviewed eight years of patient records in a private clinic in Malaysia revealed that hypertension comprised 34.1 % of medical problems and was the commonest medical problem detected during pre-employment medical examination of foreign workers [44]. For foreign workers, they are expected to be healthy for employment, although the rules allow foreign workers with chronic illnesses to be employed if they are not debilitating. Those with diseases need to be treated and there is a growing concern with regards to management of chronic diseases cases among foreigners in public clinics and how it might impose demand on the resources of the public healthcare system which is already strained. Unlike acute illnesses, treatment of chronic diseases is long term and incurs higher cost, which partly explains the preferences for public sector [45]. In this study, we found that the maximum duration of medications for chronic diseases supplied by public clinics was for six months. However, there is a new directive from Ministry of Health Malaysia to limit the supply of medications for chronic non-communicable diseases to foreigners for only five days for each consultation; the rest will have to be sourced at the patients’ own cost from the private sector [46]. This move is seen as part of an effort to reduce public healthcare spending and limiting the government health subsidies to foreigners, in light of prevailing government view point that foreigners took up 30 to 40 % of the healthcare subsidies by Malaysian government [47]. Our study however, was conducted before this policy was implemented thus future study to look into the effect of the changes in policy and further cost analysis is necessary.

A substantial proportion of encounters (13.5 %) from the private clinics are for general medical examinations. The relative frequency for general medical examination, particularly in private clinics, was to be expected because health assessment is mandatory for foreigners who are planning to work, study or seek residency in the country [22, 48]. Furthermore, most of these encounters were for pre-employment or annual health examinations required for renewal of their work permits. This requirement is conducted in private clinics registered with the Foreign Workers’ Medical Examination Monitoring Agency (FOMEMA), the agency responsible for coordinating and monitoring the task [22, 49]. The workers are screened for any condition that renders them medically unfit for employment, as mandated by the Ministry of Health Malaysia [50].

We noted six encounters with a diagnosis of tuberculosis and 45 with suspected tuberculosis. Although they formed less than 1.0 % of the encounters, the actual prevalence may be higher because more than 60.0 % of tuberculosis cases are diagnosed and treated in public hospitals [51] and therefore not included in this study. A review of Malaysian Tuberculosis Registry showed that 14.2 % of the 21,582 tuberculosis patients were foreigners [52]. Studies in several countries have shown that tuberculosis is a common infectious disease diagnosis reported among foreign migrants [37, 53, 54]. Transmission of tuberculosis is often linked to migration of people from high risk countries [55]. Hence foreign workers are screened for infectious diseases before they enter the country, although there are also many who bypass the system which further complicates the control programme. The responsibility therefore rests on physicians, especially the primary care providers as the first point of care, to have a high index of suspicion for undetected tuberculosis cases and subsequent treatment and monitoring.

Acute and minor illnesses reported among foreigners in our study population were mainly on febrile illness and respiratory symptoms, injuries, musculoskeletal complaints, and gastrointestinal problems. The frequent presentation of these conditions were also reported in studies from other countries that sampled foreign migrant workers [12, 18, 37]. A previous local study on illness pattern of foreign workers conducted in 2002 indicated that the most frequent medical complaints were injuries or accidents (19.6 %), musculoskeletal (18.0 %), gastrointestinal (16.7 %) and fever (14.5 %) [11]. By contrast, our study identified higher rates of respiratory ailments while injuries or accidents appeared to be less frequent. This could be explained by the fact that our study described cases managed in primary care clinics only, while the previous report included cases managed in the emergency departments of hospitals. Moreover, our study included all foreigners regardless of employment status or age; the health problems encountered would therefore be more diverse.