A good prognosis: Health care strategies target prevention and best practices

The nation’s universal health care system is the envy of many other countries. Through it, Brunei Darussalam has met most of the health care targets set out in the UN Millennium Development Goals (MDGs) and by the World Health Organisation (WHO), as well as internally set goals. The country has the second-highest life expectancy among the ASEAN countries, behind only Singapore. However, non-communicable illnesses like cancer and heart disease are still the biggest killers and, as the price of health care rises, the Sultanate is in the process of balancing the rising costs of care provision while maintaining the quality of its services.

STRUCTURAL DIVISION: The Ministry of Health (MoH) has established five policy pillars: promoting primary health care; focusing on the management of high-priority chronic diseases; pursuing high quality in health care; achieving a more equitable allocation of funds for diverse health services and venturing into alternative sources of health care financing; and promoting selected areas of excellence in health services.

Supporting and driving these aims has been the National Health Care Plan 2000-10, which is currently being reviewed, according to the website of the MoH. The plan is composed of seven strategic targets: promoting healthy living; strengthening primary health care; obtaining new resources for health service delivery; strengthening the management of high-priority chronic diseases; effectively managing national health emergencies; improving rehabilitative care; and achieving excellence in hospital services.

Delivery of health care is divided between the Department of Medical Services and the Department of Health Services. The former is responsible for providing hospital, nursing, laboratory, pharmaceutical, renal and dental services, while the latter oversees community and environmental health, as well as scientific services. Primary health care, such as childcare and maternal services, were decentralised in 2000 to enhance the accessibility of care. Numerous government hospitals and health clinics now provide these services.

The main government hospital is Raja Isteri Pengiran Anak Saleha (RIPAS) Hospital, which hosts a comprehensive range of medical and surgical services. In addition to RIPAS Hospital, there are three other government-run general hospitals, 16 health centres, 10 health clinics, and 22 maternal and child health clinics. Flying Medical Services teams also make monthly trips to deliver primary health care to remote villages or inaccessible areas around the country.

ON THE PRIVATE SIDE: The nation’s two private hospitals are Jerudong Park Medical Centre (JPMC) and Gleneagles JPMC Cardiac Centre. In addition to the hospitals, about 65 private general practitioners were registered with the MoH as of January 2012.

The Department of Health Services’ Community Health Services division engages in monitoring activities, administering preventive programmes, such as immunisation drives, and providing community-based preventive primary health care and school health, as well as psychological, nutrition and nursing services.

These services have contributed greatly to the nation’s low rates of communicable diseases.

KEEPING COSTS DOWN: In September 2012 during a speech in which he approved the appointment of consultants to prepare the Master Plan for the Health System and Healthcare Infrastructure for Brunei Darussalam, His Majesty Sultan Haji Hassanal Bolkiah addressed the increasing cost of healthcare.

“In facing these challenges, I hope all the relevant stakeholders, especially the MoH, will continue their efforts in making holistic approaches according to best practices,” His Majesty said, adding that best practices include cost-effective methods and holding to the principle that “prevention is better than cure”.

According to the MoH, the master plan will direct and guide the ministry’s development policies and strategies with an integrated approach. Soon after the Sultan’s speech, the MoH appointed the Innova Group, a US consultancy firm, to prepare the master plan. The plan is set to include detailed research on the status of the Sultanate’s health care system and infrastructure, recommend the best system for the country’s health infrastructure, and look at budget requirements and the possibility of endorsing public-private partnerships to carry out its recommendations.

ACHIEVING GOALS: According to a 2011 health information booklet issued by the MoH, the country has achieved most of the health-related UN Millennium Development Goals (MDGs) several years ahead of the 2015 target. Over the past few decades, Brunei Darussalam has reduced its under-five mortality rate (UFMR) and infant mortality rate (IMR) to levels consistent with those of developed nations.

The Sultanate’s IMR declined from 42.3 per 1000 live births in 1966 to 11.15 per 1000 live births in 2012, while its UFMR declined from 22.7 per 1000 live births in 1980 to just seven per 1000 live births in 2011. In addition, the Sultanate’s maternal mortality ratio (MMR) is very low. In 2010 the MMR was calculated at 24 per 100,000 live births, which gave the nation a ranking of 134th when compared globally. The country’s easily accessible reproductive health care, high percentage of hospital deliveries by skilled health personnel and successful immunisation programmes are credited with achieving this low ratio.

In 1987 the WHO granted Brunei Darussalam “Malaria-Free” status, but surveillance of the parasite is continued through the MoH’s Vector Control and Malaria Vigilant Unit to prevent re-emergence. In 2000 the country was declared free of polio. And despite an increase in the number of HIV/AIDS cases since 2006, the prevalence of HIV/AIDS in Brunei Darussalam remains low. Treatment of HIV/AIDS in Brunei Darussalam is free to citizens and permanent residents.

SLIMMING DOWN: A precursor to both diabetes and heart disease – the top two national public health menaces – obesity has become one of the fastest-growing public health problems. The number of Bruneian adults who are obese has doubled over the past 14 years to 27%, according to the preliminary results of phase II of the Brunei Darussalam Second National Health and Nutritional Status Survey 2009-11. In all, 60% of all adults in Brunei Darussalam are overweight or obese. It is a trend that appears to be spreading to children as well. The first phase of the survey found that 8.8% of Bruneian children under the age of five were overweight, with 3.3% of them hitting the obese mark.

The culprits in the national obesity epidemic are largely the same as in other countries: rapid urbanisation leading to a more sedentary lifestyle, easy access to processed, calorie-laden food and an ageing population. The eating habits of children should be reformed, according to the minister of health, Pehin Dato Haji Adanan Mohd Yusof, pointing to the finding that 8.7% of children aged one year and below were already consuming sugary drinks. As in other countries, high rates of obesity tend to incur increased health care costs and add to the need for better-trained, more highly skilled sector professionals.

With obesity becoming increasingly widespread, His Majesty has made it clear that he views leading a healthy lifestyle as one of the most important elements for quality of life. His commitments to disease prevention and healthy lifestyle promotion in order to mobilise public awareness and support for non-communicable disease (NCD) prevention and control has been championed by both community groups and businesses.

PREVENTION IS KEY: Brunei Darussalam has established the National Committee on Health Promotion as part of its effort to prevent and control NCDs. Development is under way on the National Multi-Sectoral Plan for NonCommunicable Disease Prevention and Control 2013-18. In addition, policies to encourage healthy lifestyles, such as the Health Promotion Blueprint and National Physical Activity Guidelines for Brunei Darussalam, are made widely available to the public.

Still, change can come slowly, especially when it concerns health-related habits. Dr Peter Tay, the CEO of Gleneagles JPMC Cardiac Centre, told OBG, “Because health care is almost free, people do not realise that there is a cost to being ill.” However, Tay said, “The government is pushing very hard; the [MoH’s] Health Promotion Centre is educating people.”

Dato Dr Isham Jaafar, the medical and executive director at Jerudong Park Medical Centre agreed with Tay’s take on the Sultanate’s efforts to encourage more healthy eating. “The MoH is trying to educate the public by doing road shows on healthy living and prevention, and the Ministry of Education is pushing for healthy food knowledge at every age,” Dato Dr Isham told OBG. “All the ministries are keen to tackle this issue.”

The MoH has also called on businesses to market their food products more responsibly and to reformulate products to make them healthier. The ministry’s Multi-Sectoral Plan for NCD Prevention and Control, which was shared at the WHO Western Pacific Region’s Meeting on National Multi-Sectoral Plans for NCD Prevention and Control in June 2012, includes a long-term (2013-18) target of reducing the number of overweight and obese Bruneians by 20%.

GLOBAL THREATS: In an effort to boost the Sultanate’s compliance with international health standards, ministers are cooperating to implement the WHO’s International Health Regulations (IHR) 2005. It joined 193 other countries in agreeing to put the regulations into effect in response to the emergence of international disease threats and other health risks largely caused by the exponential increase in international travel and trade. The international importance of such regulations came into sharp focus in 2003, when severe acute respiratory syndrome emerged, spread rapidly to 37 countries worldwide and killed 916 people.

The main aims of IHR 2005 are to track disease emergence, evolution and transmission, thereby preventing and controlling the international spread of disease. These regulations also provide the framework for notifying the WHO of public health emergencies and arranging for immediate international assistance.

In October 2012, 40 officials from the MoH, the Prime Minister’s Office, the Ministry of Industry and Primary Resources, the National Disaster Management Centre, and the Departments of Civil Aviation, Ports, Agriculture and Agrifood, Fisheries, Environment, Parks and Recreation, and Fire and Rescue convened a conference to review and plan for the implementation of IHR 2005. The officials identified the relevant agencies for each sector to be included as members of the National Task Force for the implementation of IHR 2005. They also finalised the plan of action for the implementation of IHR 2005 in Brunei Darussalam and developed the terms of reference for the task force. Dr Ahmad Fakhri Junaidi, the head of the disease control division at the Department of Health Services and one of the conference officials, told local media that the Sultanate will work to comply with IHR 2005 by June 2014.

Integral to implementing IHR 2005 is the new $8.4m National Isolation Centre, inaugurated in November 2012. The centre’s main function is to manage and treat patients with infectious diseases. It also fulfils a need for emergency facilities in the Sultanate. The National Isolation Centre, which was allocated for under the Disaster Management Order 2006, is based in the Pengiran Muda Mahkota Pengiran Muda Haji Al Muhtadee Billah Hospital in the district of Tutong.

The centre, as well as other services, could be important internationally. “When it comes to medical tourism, we should try to match the costs of services offered in the region and raise our profile in the region by promoting specific medical treatments such as cancer treatment and rehabilitation,” Dr Tay told OBG.

HALAL PHARMA: Building on its reputation for having one of the world’s highest levels of halal certification, the Sultanate is aiming for halal pharmaceutical industry to have a key role in economic diversification.

When operational, Vivapharm – a joint partnership between Canadian Viva Pharmaceutical, Aureos (Brunei) Capital Fund and other investors – will be the country’s first halal pharmaceutical and nutraceutical manufacturer, focusing on exporting these products to the regional markets of the world that have large Muslim populations. Viva Pharmaceutical is building an international-standard manufacturing facility in the Lambak Kanan (East) Industrial Estate in the Brunei-Mara district, requiring total investments of BN$26m ($20.25m). Construction should be complete in 2013.

OUTLOOK: While NCDs and costs must be kept at bay, overall the Sultanate has much to be proud of regarding its health care and a solid record to build upon. Moves toward extending its reach to pharmaceutical production and health tourism in tertiary cardiac care cancer and rehabilitation facilities bode well for the sector.