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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
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
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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
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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
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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).
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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
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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
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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
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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
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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)
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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
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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
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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
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•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 &
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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.
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• 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
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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.
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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
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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
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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
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