The Role of Public Health Professionals i H l h D lin Health Development:Lessons from Malaysiay

Prof Maznah Dahlui and Prof Awang Bulgibaf lUniversity of Malaya

AcknowledgementTh f ll i l h t ib t d t i l & lid

Acknowledgement The following people have contributed material & slides: Dr Sirajoon Noor Ghani

i f Chi (S ) Associate Prof Ng Chiu Wan (SPM Dept, UM) Associate Prof Victor Hoe (SPM Dept, UM) Associate Prof Noran Hairi (SPM Dept, UM) Dr Maslinor Ismail (SPM Dept, UM) Dr Chan Chee Koon (Faculty of Economy)

2

Outline

f bl h l h f l

Outline

1. Training of public health care professionals in Malaysia

2. What these Malaysian public health care workers doworkers do 

3. Future of Malaysian public healthcare & its effect on training

3

Training of modern public healthTraining of modern public health professionals in Malaysiap y

4

Development of PH Workforce

definition of essential public health services (as opposed to specific public health professions) for the country & p p p ) yorganisation is important

workforce development requires assessment of national, local& organizational ability to implement training & other workforce development programs

flexible and multi‐disciplinary public health workforce required for  rapidly changing environment, including a changing health sectorsector

life‐long training is a critical component of any workforce development programmedevelopment programme

support required to ensure workforce that includes key cultural groups and cultural competenceg p p

5

Development of PH Workforce overall public health workforce development strategy that is coordinated & funded is fundamental to ensure competent public health workforcehealth workforce 

we need to facilitate establishment of organisational competencies and a more coherent programme of training opportunitiesand a more coherent programme of training opportunities

systems approach required starts with core public health functionsstarts with core public health functions leading to organisational competencies leading to individual competencies provides useful framework for discussing workforce development

workforce development needs to be linked to overall public health lgoals

person‐ & community‐centred approachd d f d d l f l h h h consider needs of individual, family or community rather than the 

perceived needs of practitioners 6

A combination of approaches

most countries have used a combination of approaches to health workforce developmentI N Z l d h H l h W kf Ad i C i (2001) In New Zealand, the Health Workforce Advisory Committee (2001) outlined 3 major components of workforce development: planning for the quantity and configuration of the workforce planning for the quantity and configuration of the workforce educating and training to ensure the quality of the workforce managing to ensure the performance and retention of an appropriately trained 

workforce 

Malaysia also takes into account the following to plan its public h l hhealth care Workforce to population ratio Student admissions Student admissions Needs‐based planning Demand‐based planning Benchmarking Model of Care approach 7

Competency C t d fi d l bi ti f

Competency  Competency defined: a complex combination of knowledge, skills and abilities demonstrated by organization members that are critical to the effective andorganization members that are critical to the effective and efficient function of the organization (Ctr for PH Practice, Emory University)

Knowledge, skills and attributes which are required to accomplish the desired outcomes.  Generally accepted but may be exemptions for individual jobs depending on actual job requirements (CDC/ATSDR Master Development Plan)job requirements (CDC/ATSDR Master Development Plan)

Source: Competencies to Curriculum Tool‐Kit: Developing Curricula for the Public Health Workforcethe Public Health Workforce

8

Competency Basics can be acquired through experience performance support

Competency Basics can be acquired through experience, performance support systems, and on‐the‐job training & not just formal training

should be included in public health workforce pdevelopment efforts

individual competencies intersect with organizational performance standards & capacitiesperformance standards & capacities

competency sets may apply broadly to public health workers or be specific to a small subsetworkers or be specific to a small subset

express a standard level of worker performance need to be routinely updatedy p

Source: Competencies to Curriculum Tool‐Kit: Developing Curricula for the Public Health Workforcethe Public Health Workforce

9

Competency Sets

Core – basic public healthe.g. Council on Linkages

Topical TopicalE.g. bioterrorism, law, genomics, informatics

FunctionalE.g. technical, support staff, professional or leaderE.g. technical, support staff, professional or leader

Discipline specificE.g. environmental health, laboratory, nutrition, health education

10

3 levels of public health competency Basic Competency: a basic understanding of what public health is, what it does & how it is achieved

Cross cutting (Core) Competencies: general knowledge, skill and ability in areas which enable performance of one or more 

lessential services competence in epidemiology, policy development, health 

communications community needs assessment & mobilisation &communications, community needs assessment & mobilisation &behavioural sciences

Technical Competencies: defined programme areas require specific technical knowledge, skills & abilities represent unique application of skills to a particular health problem or 

issueissue may build upon basic and core competencies (e.g. control of 

communicable disease, chronic disease prevention, environmental health).

11

Process for Public Health Competency Integration

Essential Public

Assessment Data Validate Linked

Competencies Health Services

Competency SetsReview

pand Objectives

Council on Linkages Competencies

Competency Sets (discipline, functional or

topic specific)

ReviewCourse Content

ReviewLearner

Objectives

CourseImplementation

EvaluationMethods DemonstratePerformance

Outcomes MethodsCompetenceOutcomes

12

Health professionals in Malaysia1 B i i P bli H l h A i

Health professionals in Malaysia1. Basic competencies: Public Health Assistants, 

Assistant Environmental Health Officers, Public H l h N C i N M di lHealth Nurses, Community Nurses, Medical Assistants

2. Cross cutting (Core) Competencies: Health Officers3. Technical Competencies: Epidemiologists, Health p p g ,

Economists, Family Health Specialists, Health Services Management Specialists, Occupational g p , pPhysicians, Environmental Health Specialists

13

Where they are trained Basic competencies:  trained in colleges across Malaysia initially certificate level now diploma level

Cross cutting (Core) Competencies:  trained in universities MPH Master of Health Promotion

Technical Competencies: trained in universities DrPH PhD Sub‐speciality training 

14

What these Malaysian public healthWhat these Malaysian public health care workers do

15

Pre independence health care in MalaysiaPre‐independence health care in Malaysia

N h i k b l h l h Not much is known about early health care Early health care provision concentrated around: Malay traditional medicine ‐ blend of folklore Hindu mythologyy gy Muslim orthodoxy  Arab pharmacopoeia Arab pharmacopoeia 

16

Malaya history Melaka Sultanate Melaka Sultanate

1400 ‐ Parameswara establishes sultanate Portuguese rule

1511 P t t M l k 1511 ‐ Portuguese captures Melaka Two hospitals built by Portuguese 

Dutch rule 1641 ‐ Dutch captures Melaka  Surgery Clinic & Hospital ‐ for Dutch 

citizenscitizens British rule in Malaya

1786 ‐ British settlement in Penangg 1795 ‐ British capture Melaka 1819 ‐ British purchase Singapore from 

l l llocal ruler built Garrisons with hospitals or infirmaries 

for care of European officials and families 

17

p Modern public health as we know it was non‐

existent

Pre independence MalaysiaPre‐independence Malaysia

Work on providing public health care started in 1950s Rural Health Service Scheme (1953‐56)Rural Health Service Scheme (1953 56) First Rural Health Centre built in 1953 P id d MCH i ith i i l ti i Provided MCH services with minimal curative services By the end of 1960s, the number grew to 8 main health centres (MHC), 8 health sub (HC) centres and 26 midwife clinic cum quarters (MCQ), with 18 maternal and child health clinics (MCHC)

18

Pyramid of Health Services

Ministry of Health

Specialised National Institutes

and 

re

University Hospitals

Second

ary a

Tertiary Car

Regional Health Services

District Health Services & Hospitals (first referral level)

S T

lth‐

m, now

 ” referral level)

Community Health Centres (intermediate level)

er ru

ral hea

ivery syste m

district level”

Community Dispensaries & Village Health Posts

Ref: McMahan R (Ed): On Being in Charge: A Guide to Management in Primary Health Care 2nd Ed WHO Geneva 1992

Three‐ti

care del

called “ d

19

Ref:  McMahan, R (Ed): On Being in Charge: A Guide to Management in Primary Health Care, 2nd Ed. WHO, Geneva, 1992

Public Healthcare in Malaysia• There are public & private health care providers 

Public Healthcare in Malaysiap p p

• The Ministry of Health (MoH) is the main health care provider• The ministry operates a wide network of hospitals and clinics y p p

sited throughout the country• There are about 146 (MoH & non‐MoH) government hospitals 

throughout the country with 41,616 beds in 2011• These hospitals are supported by (2013 figures):

• 1039 Health Clinics• 1,864 Community Clinics• 5 Flying Doctor services• 254 1Malaysia Health Clinics

8 1 l i bil Cli i• 8 1Malaysia Mobile Clinics

20

Public Health Facilities

21

Private Hospitals

22

From 1956 to 2011From 1956 to 2011

Health facility 1956 2011

Community clinics 26 1 864Community clinics 26 1,864

Health clinics 16 985(1031 in 2013)

Private clinics ‐ 6,589

Government hospital & institutions

65 146institutionsPrivate hospitals 50 220

23

Public Health ProfessionalsPublic Health Professionals2013 MOH Non  Private Total2013 MOH Non 

MOHPrivate Total

Medical Officers 28949(M&HO 

6270 11697 46916 1:6(M&HO ‐ 5%)

Assistant Medical Offi  

10641 ( %)

448 1428 12517 1:2Officers  (50%)

Community Nurses 23971 181 267

Assistant Health Environment Officers

4287

Gazetted PH Physicians 400 200y 4

24

Organisation Chart for Ministry of Health, MalaysiaMINISTER OF HEALTH

DEPUTY MINISTER OF HEALTH

SECRETARY GENERAL

PARLIAMENTARY SECRETARY

SECRETARY ‐ GENERAL

PUBLIC RELATIONS OFFICER

DIRECTOR – GENERAL OF HEALTH

DEPUTY DIRECTOR    ‐GEN (MEDICAL)

DEPUTY DIRECTOR  – GEN. (PUBLIC HEALTH)

DEPUTY DIRECTOR – GEN. (RESEARCH & TECH SUPPORT)

LEGAL ADVISOR

INTERNAL AUDITOR

GEN. (MEDICAL)(PUBLIC HEALTH) (RESEARCH & TECH. SUPPORT)

• Dental Services

• Disease Control

H lth Ed ti

•Medical Development

•Medical Practice • Pharmaceutical Services

• Engineering Services• Health Education

• Food Quality Control

• Family Health Development

Engineering Services

• Planning & Development

• Institute for Medical Research

DEPUTY SECRETARY –DEPUTY SECRETARY –GEN. (Management)

DEPUTY SECRETARY GEN. (Finance)

•Management • Finance

13 STATE HEALTH DIRECTORATES

• Kuala Lumpur • Perlis • Neg. Sembilan

• Sabah • Penang • Malacca•Management              – International Section

• Human Resource        – Establishment Section‐ Promotion Section

‐ Budget‐ Revenue

• Procurement & Privatisation

• Accounts

• Sarawak • Kedah • Pahang

• Kelantan • Perak • Terengganu

• Johore • Selangor

25

•Manpower Planning & Training

• I.T Centre

Organization of State Health DepartmentOrganization of State Health Department

Director of Health

Deputy Director (Mgt)

Deputy Director (Med)

Deputy Director (Dental)

Deputy Director (PH)

Deputy Director (Pharm)

Director of Hospital District Medical Officer of Health

26

Organization Chart for District of Health

District Health Office

Health Services Administrative Support

Family Health

Nutrition

Quality Assurance

Human Resource Management

Financial Management

Resource and Supplies 

Management

Health Promotion and Education

Food Quality

Health Management Information 

(HMIS) Budget Accounts Expenditure IncomeFood Quality Control

Environmental Sanitation

Budget Accounts Expenditure Income

Water Quality Control

Workers & 

27

Environmental Health

Family Health Services1. Family Health

• Maternal Health• Maternal Health

Ante Natal Clinics Safe Deliveries Hospital Alternative Birthing Centres 

(ABC) Domiciliary delivery Post Natal Care Family Planning Screening – Pap smear, etc.

28

• Child Health

Infant healthInfant health Immunisation Toddler/PreschoolToddler/Preschool School Health

• Nutrition Services

2. Primary Health Care2. Primary Health Care

• Outpatient Clinics Hospital

Health Centres

29

Disease ControlDisease Control1. Vector‐borne disease

Malaria DengueDengue Filariasis, etc

2 AIDS/STD2. AIDS/STD

30

3 C i bl Di3. Communicable Diseases

• Food & water‐borne

Cholera

Typhoid Typhoid

Dysentery  etc.

4. Non‐communicable Diseases4. Non communicable Diseases

Cardiovascular Diseases

Cancer

Diabetes etc.

31

Workers & Environmental 

Health• Health promotion in worksites

• Health screening of workers• Health screening of workers

• Worksite inspection with 

Dept. of Occupational Safety & Health

Dept. of Environment

32

Food Quality Control ProgrammeFood Quality Control Programme• Surveillance programme

Premises inspection

Food sampling

• Enforcement

• Prosecution

Health Education Programme• Health Education activities for the above

• Healthy Lifestyle promotion

33

y y p

Environmental Sanitation & National Water Quality Programme

• Sanitary facilities in villages e g• Sanitary facilities in villages e.g. toilets

W t l• Water supply

monitoring of water supply

gravity feed system

• Sullage and solid waste disposal• Sullage and solid waste disposal 

34

35

36

37

Current scope of services in health clinics Curative Services Curative Services Family Health Dental Services Dental Services Nutrition and Dietetics Health Education/Promotion Health Education/Promotion Home Nursing, Care of the Elderly Rehabilitative Services Rehabilitative Services Environmental Sanitation Well Women Clinics Well Women Clinics Adolescent Health Community Mental Services etc

38

Community Mental Services, etc

Health Status of Malaysians (2011)M l i l ti f 28 9 illi i 2011 (63% b t 15

Health Status of Malaysians (2011)• Malaysian population of 28.9 million in 2011 (63% between 15 

to 64 years old, 32% below 15 and 5% above 65)• Life Expectancy: male 71 9 female 77 0• Life Expectancy: male 71.9, female 77.0• Crude birth rate is 17.5 per 1000 population• Crude death rate is 4 8 per 1000 population• Crude death rate is 4.8 per 1000 population• Infant mortality rate is 6.8 per 1000 live births 

M t l t lit t i 27 3 100 000 li bi th• Maternal mortality rate is 27.3 per 100,000 live births• Total expenditure on health RM33.7 billion or USD10.8 billion

T l E di f H l h f G D i• Total Expenditure for Health as a percentage of Gross Domestic Product (GDP) was 4.96% of GDP

39

The future of Malaysian publicThe future of Malaysian public healthcare & its impact on trainingp g

40

The 3 Grand Challenges of the FutureThe 3 Grand Challenges of the Future

1. Rise in lifestyle diseases2 Ageing population2. Ageing population3. Rapidly spreading infectious diseases

41

Lifestyle diseases Rise in lifestyle diseases (heart disease, cancers) in tandem with sedentary lifestyles & environmental tandem with sedentary lifestyles & environmental changes

Preventive and promotive care is more cost effective Preventive and promotive care is more cost effective than curative care

The new healthcare model must take cognisance of The new healthcare model must take cognisance of this fact

42

By 2035 >10% of Malaysia’s population will be 60Ageing population

By 2035, >10% of Malaysia s population will be 60 years or olderH l h i hi f d k Health care must recognise this fact and take steps to prepare for it

The future healthcare system must cater for this group of people 

43

Rapidly spreading infectious diseases Emerging and re‐emerging diseases pose a major threat to M l i d

Rapidly spreading infectious diseases

Malaysians today Ability to harness all healthcare resources is key to controlling outbreaksoutbreaks 

Origin & spread of the Black Death in Asia

44

Origin & spread of the Black Death in Asia

45

Infectious diseases spread faster than ever beforep

46

Rising to the challenge Malaysia’s Public Health training needs to prepare itself t t th G d Ch llto meet these Grand Challenges

Staff capabilities will need to increase dramatically Lifestyle disease expertise Ageing issues expertise Real‐time spatio‐temporal infectious disease modelling Quick response infectious disease teamQu c espo se ect ous d sease tea Health policy advisory roles

Better working relationship with other agencies Better working relationship with other agencies Interfacing of data from other agencies

47

ExpertiseExpertise 

h l f bl l h d The list of Public Health experts needs to grow The depth of expertise also needs to growp p gMalaysia will need to invest heavily in these areas: Capacity building Building up selected resources & facilities Extending and strengthening collaborative networks Extending and strengthening collaborative networks

48

New roles for Malaysia’s academic ypublic health departments

Advanced training for future public health professionals

Advocacy for a better quality of life Advocacy for a better quality of life Advisory role to governments & NGOs Active involvement in niche areas

49

Some challenges will result from TechnologyMaking IT the enabler for all this EnvironmentMaking the environment conducive for this to happenMaking the environment conducive for this to happen Cost of health careM ki h i i f bli h l hMaking enough provision for public health careGetting all parties to agree Community participationMaking the community the driving force behind health g y gcare

50

I hopeTh t th f t M l i bli h lth f i l ill

I hope … That the future Malaysian public health care professional will have the following characteristics:

1 Be truly tech savvy1. Be truly tech‐savvy2. Be able to understand & exploit inter‐agency collaborations3 Be a really strong advocate of preventive and promotive3. Be a really strong advocate of preventive and promotive

rather than curative care to address the epidemic of lifestyle diseasesdiseases

4. Be able to address the problem of equitable access and care of an ageing populationg g p p

5. Be more prepared for better epidemiological control of emerging infectious diseases and non‐communicable diseases

51

52