Tembeling 2.0

Tag: public health

  • When population health is no longer a priority

    https://jamanetwork.com/journals/jama/fullarticle/2846529

    The recent Perspective article in JAMA raises a deeply unsettling argument. The problem facing population health is no longer simply neglect. It is the growing possibility that policy decisions themselves are beginning to work against health.

    The authors describe how, over the past decade, the United States has already experienced stagnation and even decline in key health indicators such as life expectancy. This was not unexpected. For years, public health experts had pointed to the structural determinants that shape health outcomes, including access to healthcare, socioeconomic inequality, education, environmental exposures, and the strength of public health institutions.

    The solutions were not unknown. Expand access to care. Strengthen social protection. Regulate harmful industries. Invest in science and public health systems. Address inequality. These are long-established principles supported by evidence.

    What is new, and concerning, is the shift away from these solutions. The article argues that recent policy directions have not merely failed to improve population health but may actively undermine it. Reductions in support for scientific research weaken the evidence base that informs policy. Erosion of public health protections reduces the ability to prevent harm before it occurs. Policies that increase social and economic vulnerability widen health inequities.

    In this framing, worsening population health is no longer an unintended consequence. It becomes predictable. When policies disregard the foundations of health, outcomes follow accordingly.

    This perspective invites reflection beyond the United States.

    In Malaysia, several structural signals warrant attention.

    First, the burden of disease is already high. Malaysia has one of the highest prevalences of obesity in Asia, accompanied by a growing burden of non-communicable diseases. This reflects sustained exposure to behavioural and environmental risks, particularly dietary patterns that are deeply embedded in daily life.

    Second, the healthcare system is under strain. Workforce challenges, including shortages, migration, and burnout, are increasingly evident. A constrained workforce limits the system’s ability to balance curative services with preventive and public health functions, shifting focus towards short-term demand rather than long-term health outcomes.

    Third, there are gaps in policy and enforcement related to known health risks. Tobacco control, including the regulation of e-cigarettes, remains an area of concern. Reluctance to implement and enforce stronger measures risks sustaining nicotine dependence and enabling new patterns such as dual use, particularly among younger populations.

    These are not isolated issues. They represent interconnected elements within the broader population health landscape.

    The concern is not that Malaysia is currently adopting policies that directly undermine health. Rather, it is the possibility that, without decisive and sustained action, existing conditions, cultural norms, and policy hesitations may collectively produce similar effects.

    The lesson from the JAMA article is clear. Population health is shaped by policy choices. When health is not consistently prioritised across sectors, deterioration becomes a foreseeable outcome rather than an unexpected one.

    Malaysia remains at a point where the trajectory can still be shaped. Recognising these signals early allows for a more deliberate response, ensuring that population health remains central in policy and practice, rather than becoming an afterthought.

  • A principled perspective on the roles of Public Health Medicine Specialists and PTD officers in the Ministry of Health

    The discussion on whether Public Health Medicine Specialists (PPKA) can replace or assume roles currently held by PTD officers must be framed correctly. It is not fundamentally a question of replacement, but rather a question of role alignment, competency utilisation, and leadership development within a complex health system. Any modern health system functions best when professional expertise and administrative competence complement each other, not when one is viewed as substituting entirely for the other.

    The foundational principle of professional and administrative competence

    A key principle in organisational leadership, particularly in highly specialised sectors such as healthcare, is that it is generally easier to train a technical expert in administrative and management functions than to train a general administrator to acquire deep professional and technical expertise. This is because professional training in medicine and public health requires many years of structured education, supervised practice, and competency development. Public Health Medicine Specialists undergo rigorous training through Master’s and often Doctor of Public Health programmes, covering epidemiology, health systems, health policy, programme planning, management, and evaluation. Their training inherently integrates management principles within the context of health systems, rather than management in isolation.

    In contrast, PTD officers enter the civil service with diverse academic backgrounds, often without specific training in healthcare, epidemiology, or health systems. However, they bring valuable strengths in governance, administrative procedures, finance, policy implementation, and organisational coordination. These competencies are essential for the functioning of large institutions such as the Ministry of Health. Their role is therefore complementary, not inferior nor superior, but different in nature.

    The unique training and competency of Public Health Medicine Specialists

    Public Health Medicine Specialists are uniquely trained to understand the health system as a whole. Their competencies include disease surveillance, epidemiological analysis, programme planning, prevention and control strategies, health policy development, and health system evaluation. Importantly, their training also includes management and leadership within healthcare settings. They are trained not only to analyse disease patterns but also to design and implement interventions at population level, coordinate services across sectors, and evaluate outcomes.

    This gives them a critical advantage when making decisions that directly affect health service delivery, disease prevention, and population health outcomes. Their decisions are informed by both scientific evidence and operational realities. For example, an epidemiologist overseeing disease surveillance does not merely analyse data but plans preventive strategies, allocates resources based on risk, and coordinates responses across multiple levels of the health system.

    Their management training is therefore context-specific. It is grounded in healthcare realities, which makes them particularly suited for leadership roles that require integration of clinical, preventive, and system perspectives.

    The appropriate positioning of Public Health Medicine Specialists within the health system

    Public Health Medicine Specialists should primarily be recognised and positioned as specialists, equivalent in professional standing to clinicians in hospitals. Just as clinicians lead clinical services based on their expertise, Public Health Medicine Specialists should lead technical areas such as disease surveillance, prevention programmes, health policy planning, and population health strategy.

    Many specialists, whether clinical or public health, naturally progress into administrative and leadership roles as part of their career development. Their technical background strengthens their administrative effectiveness because their decisions are grounded in real-world professional experience. This is consistent with the model seen globally, where healthcare organisations are often led by individuals with professional training in medicine or public health, supported by administrative professionals.

    However, this does not mean that all specialists must become administrators. Many should remain focused on technical leadership, which is essential for maintaining the integrity and effectiveness of health programmes.

    The continued relevance and complementary role of PTD officers

    PTD officers play an important role in supporting the health system. Their expertise in public administration, finance, human resource management, and policy implementation (if they really have the expertise) provides essential organisational support. They facilitate the operational and administrative processes that allow technical specialists to focus on professional and programme leadership.

    Rather than viewing the roles as interchangeable, it is more accurate to view them as complementary. PTD officers can support specialists by managing administrative systems, while specialists provide technical direction and professional leadership. This collaborative model ensures both administrative efficiency and technical excellence.

    Leadership roles must be determined by competency, not professional category alone

    Leadership is not automatically determined by whether an individual is a Public Health Medicine Specialist or a PTD officer. Leadership requires specific competencies including strategic thinking, decision-making, communication, integrity, and the ability to guide organisations effectively. These competencies must be developed over time through training and experience.

    Not all specialists are suited for leadership roles, and not all administrators are suited for technical leadership roles. Both groups require leadership development if they are to assume senior management positions. The key principle is that leadership roles must be assigned based on demonstrated competency, relevant experience, and suitability, rather than professional designation alone.

    Where leadership involves technical decision-making related to health systems, disease control, or service planning, individuals with professional health expertise have a natural advantage because they understand the implications of decisions at both clinical and population levels.

    The relationship between directors, deputies, and administrative leadership

    In many healthcare systems, directors provide strategic and professional leadership, while deputies support operational coordination, administrative implementation, and organisational management. When deputies have professional health expertise, this can strengthen decision-making by ensuring that operational and administrative decisions align closely with technical realities.

    However, administrative expertise remains essential. Administrative officers provide continuity, governance, and procedural oversight, ensuring that organisational systems function efficiently.

    The most effective model is therefore one where technical leadership and administrative expertise work in partnership.

    Leadership at the Ministry level and the distinction between administrative and technical leadership

    At the highest levels, such as the Secretary-General and Deputy Secretary-General positions, leadership involves national-level policy implementation, resource allocation, organisational coordination, and governance. These roles require strong administrative and leadership competencies, as well as an understanding of the health system.

    Whether such roles are held by individuals with health professional training or administrative training depends on their competency, experience, and leadership capability. Individuals with public health expertise bring strong understanding of health systems and population health, while those with administrative training bring strengths in governance, policy coordination, and organisational management.

    Both backgrounds can contribute effectively if the individual possesses the required leadership and management competencies.

    Conclusion

    The issue is not whether Public Health Medicine Specialists should replace PTD officers, but how both groups should be optimally positioned to strengthen the health system. Public Health Medicine Specialists should be recognised as professional specialists with leadership roles in technical and health system domains, equivalent in standing to clinical specialists. PTD officers should continue to provide essential administrative and governance support.

    Leadership roles should be determined based on competency, experience, and suitability, not solely professional designation. Both specialists and administrators have important roles, and the most effective health system is one where professional expertise and administrative competence work together in a coordinated and complementary manner.

    This approach ensures that decisions affecting health services and population health are both technically sound and administratively effective, ultimately strengthening the overall performance of the Ministry of Health.

  • PrEP Must Be Implemented with Mandatory Behavioural Intervention

    From a public health perspective, harm reduction is not confined to lowering biological risk alone. It must also address the behaviours that generate that risk. While HIV pre-exposure prophylaxis, or PrEP, is effective in reducing the probability of HIV transmission, it does not modify sexual risk behaviour and cannot replace personal responsibility or behavioural change.

    From the standpoint of the Health Belief Model, behaviour is strongly influenced by an individual’s perceived susceptibility and perceived severity of harm. When PrEP is introduced without structured behavioural intervention, it may substantially reduce the perceived risk of HIV transmission. This lowered perception of harm weakens the motivation to change behaviour, resulting in the continuation, or even escalation, of high-risk sexual practices. In this context, PrEP risks undermining the behavioural drivers essential for sustainable prevention.

    When PrEP is promoted without mandatory and structured behavioural interventions, it ceases to function as genuine harm reduction and instead becomes a mechanism that enables the continuation of unhealthy and high-risk sexual behaviours under the false assurance of biomedical protection. This represents a shift from prevention to harm containment, which is inconsistent with established public health principles.

    Beyond biomedical and behavioural considerations, public health interventions must also recognise the moral, ethical, and spiritual dimensions of human behaviour. For Muslim communities in particular, health promotion should not be detached from faith. Islam emphasises accountability before God, moral conduct, self-restraint, and the pursuit of what is good and beneficial for oneself and society. Prevention strategies should therefore encourage individuals not only to avoid harm, but also to return to values grounded in belief in God and commitment to doing good.

    Crucially, HIV prevention and control cannot be addressed by the Ministry of Health alone. It requires a deliberate, coordinated, and sustained multi-agency approach. Ministries responsible for education, youth and sports, higher education, religious affairs, social welfare, women and family development, as well as law enforcement, community leaders, religious institutions, non-governmental organisations, and families must all share responsibility. Behaviour, values, and social norms are shaped far beyond the healthcare system, and ignoring this reality weakens any national response.

    The provision of PrEP must therefore be embedded within a comprehensive and structured prevention framework that is multi-sectoral by design. This includes rigorous behavioural risk assessment prior to initiation, continuous sexual health counselling, reinforcement of safer practices, adherence monitoring, and periodic reassessment of ongoing need, supported by education, moral guidance, and community engagement across multiple agencies. Without these elements, the use of PrEP risks normalising sustained high-risk behaviour and may contribute to rising rates of other sexually transmitted infections.

    A relevant comparison is nicotine replacement therapy. Nicotine patches are never offered in isolation. They are part of structured cessation programmes with counselling, monitoring, and a clear objective of stopping smoking. PrEP, in contrast, is too often framed as a long-term biomedical solution without a defined behavioural trajectory or exit strategy. This difference is significant and must be addressed in policy and implementation.

    If the Ministry of Health advocates PrEP as part of the national HIV prevention strategy, it carries a responsibility to ensure that its delivery is ethically sound, behaviourally anchored, and evidence informed. Biomedical tools must support behavioural change, moral responsibility, and ethical reflection, not substitute for them, and this must be reinforced through coordinated action across agencies.

    PrEP can play a role in HIV prevention, but only as an adjunct within a structured, monitored, behaviour-focused, values-conscious, and genuinely multi-agency strategy. Sustainable HIV control will not be achieved through medication alone. Behavioural modification, ethical responsibility, moral guidance, and shared societal accountability remain central and must be treated as non-negotiable components of any effective national HIV prevention programme.