Written by Dr L. W. Jayesuria, Deputy Director of Medical Services (Health), Ministry of Health Malaysia
Date of Publication: 1967
The Ministry of Health in 1963 prepared a manual on “The Organisation of Rural Health Services in Malaya” which provided guidelines for developing a balanced and integrated curative and preventive health service and a better insight into matters of practical nature in rendering educational and technical health services to the people. The contents of the manual are flexible enough to enable public health administrators and field health workers to make changes in the light of experience as it accumulates with the progress of the rural health development programme and with the improvement in the social and economic conditions in the country. The Rural Health Services Scheme is not perfect and modern public health methods and techniques suitable to meet the current health needs and problems of the people are being formulated and tested. In the course of time, a pattern of rural health services would be gradually developed for the needs of the rural masses and for the achievement of a healthier and prosperous nation.
The objective of this paper on “A Review of the Rural Health Services in West Malaysia” is to assess the development progress made since the inception of the Rural Health Services Scheme. The views expressed and materials presented in this paper are in line with those prescribed in the manual on “The Organisation of Rural Health Services in Malaya” with emphasis on phases of the health programme which are consistent with the national objectives and policies on social and economic development of the country. This paper comments on the problems and difficulties encountered during the process of implementing the Rural Health Services Scheme and on the achievements in terms of objectives and accomplishments against set targets and work load. The statistical and informational data collected will show the impact and the effects of the health services on the health status of the people. The current rate of population growth is more than 3% with an overall natural increase of 31 per thousand population. About 60% of the total population are under 20 years of age. The high increase in population will continue to grow as majority of the people are in the young age group. Although there has been a gradual decline in the mortality rates, there are still certain segments of the population and certain parts of the country, the so-called “dark areas”, where mortality rates and incidence of diseases continue to be high.
The health programme achievements during the first and second five-year periods of the development plans have been largely due to the dedication, imagination and energy of the Ministry of Health Officials at the various levels of its organisation. We have to take into account the acute shortage of public health trained professional and auxiliary health workers, particularly during the transition period immediately after the country attained its independence, and the time element to train personnel needed for the expansion and improvement of the medical and health services in the country.
The World Health Organization has provided technical assistance in strengthening the organisation and operation of rural health services and health personnel training. UNICEF has extended material assistance to the Rural Health Development Programme envisaged under the Five-Year Development Plans in the form of equipment, supplies and transport. This paper was presented during the meeting of the National Health Council at the Conference Room, Ministry of Health, 12 November, 1966.
TAN SRI DR MOHD. DIN BIN AHMAD, P.M.N., Setia-usaha Tetap/ Pengarah Perkhidmatan Perubatan, Kementerian Kesihatan.Malaysia
In the social and economic development plans of the Government of Malaysia, top priority was given to expansion and development of adequate health services into the rural areas. The primary aim of the Government was to raise the health standard of the rural people who comprise about 75% of the total population. It had to be recognised that the lives and state of health of the rural people have economic values in terms of human economic productivity and in terms of Government’s expenditure required for medical and health services to keep the people healthy to work and serve the country. Loss of lives or absence from work due to illness can bring economic loss not only to the country but to the family as well. This loss could be manifested in the lowering of standards of living, the necessity by the Government to provide more funds for medical assistance, and the loss or lack of manpower and money for the social and economic development projects. Poverty and health are reciprocally related. Poverty can be the direct cause of ill-health and long standing illness may result in poverty. Poverty in turn could influence the incidence of diseases and malnutrition by its association with ignorance and a negative social attitude. A vigorous attack on diseases and other conditions undermining health is fundamental in breaking the recurrent cycle of illness and poverty.
The objectives of the Rural Health Services were not merely to reduce the number of deaths and incidence of diseases but also the attainment of optimum health by all the people. In the achievement of the objectives, the definition of “HEALTH” by the World Health Organization would have to be considered in all its entirety. The definition states that “Health is the state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” The human factor is therefore fundamental to national progress and the protection and promotion of health and well-being of the people must underlie any programme to raise the standard of living. If maximum benefits are to be derived from concerted efforts of Government and people to raise the standard of living in the country, health must go hand in hand with other social and economic development programmes and a dynamic balance must be maintained as development programmes move onwards.
RURAL HEALTH DEVELOPMENT PLANS
In the Development Plans, 1954-1956, the then Government of the Federation of Malaya formulated a tentative national rural health programme. The basic plan called for:
- trained rural midwives, one per 2,000 people;
- a sub-district health centre, one per 10,000 persons, including health centre staff and the five midwives of the area; and
- district health centre, one per 50,000 persons serving as a sub-district health centre in its own area and as head quarters for four other sub-district health centres.
For a rural population of 4½ million, 90 district health centres and 360 sub-district health centres were envisaged m the plan. These plans were to be financed by the Colonial Development Fund.
1.1. It was contemplated to establish 25 health centres but only 8 district health centres were constructed during the period 1954-1956.
1.2. Large scale staff recruitment and training was considered as an essential part of the development plan and it would take many years to carry out the training programmes necessary to meet the requirements for the pre-existing and future services. A rural health training school was established at Jitra, north of Alor Star, Kedah, with assistance from the World Health Organization and UNICEF.
1.3. The development of a comprehensive rural health service was complicated by the national emergency, especially by the resettling of 10% of the country’s population to new villages and resettlement areas. The resettling created new health hazards and needs by bringing together families accustomed to living in widely scattered areas.
l.4. The administrative and financial problems of the Government of the Federation of Malaya during these periods necessitated the re-consideration of the future development plans for the country.
1.5. In January 1954, a mission organised by the International Bank for Reconstruction and Development was commissioned by the Government of the Federation of Malaya to assess the resources available for future developments, to consider how the resources might best contribute to the social and economic developments of Malaya, and to make recommendations for practical measures to further such development.
2. The First Five-Year Plan, called the General Plan of Development, 1956-1960. was created for the Federation of Malaya. The Rural Development Plan was embodied in this First Five-Year Plan. The mission recommended that the rural health development programme be given high priority and be carried forward vigorously. It was suggested that 24 rural health centre be developed in the years I956-1960 and a second rural health training school be established in the south for the development of staff needed for these and future health centres.
2.1. In August 1957, upon attainment of independence, a new constitution was introduced which entailed changes in the Government machinery. The assumption of the executive authority by the Ministry of Health did not take effect until the 1st January, 1958. The administration of medical and health services was transferred from each State Government to Federal Government’s responsibi lity, with the exception of health and preventive work in local authority areas where the local body has assumed the responsibility. It was necessary for the Ministry of Health to establish new policies on the organisation and administration of the medical and health services including the Rural Health Services and public health training programmes, at the federal and state, district, local and rural health centre levels of administration.
2.2. Land being a State Government responsibility, the Federal Government had difficulties in obtaining land for siting the rural health centres and midwives’ clinic cum quarters.
2.3. Training programmes which were State responsibility prior to independence, were also held back due to delay in recruitment and lack of local people who would like to work in public health. Moreover, the training programmes were not organised, coordinated and geared to meet the required personnel for the pre existing and future needs of the health services. The second rural health training school as recommended by the mission was not established during the First Five-Year period of the plan.
2.4. In the implementation of the Rural Health Services Scheme, each State encountered problems related to:
- organisation and administration of the rural health services;
- obtaining state land for siting the rural health centres and midwives’ clinic-cum-quarters;
- frequent changes and transfer of staff;
- supply of qualified and public health trained professional staff and auxiliary workers;
- adequacy of supervision. particularly over the auxiliary health workers;
- lack of transport for more mobility of supervisory staff and of field workers; and
- the coordination or integration of previously existing static or travelling dispensaries and clinics. maternal and child welfare clinics or centres, dental clinics, etc., into the matrix of the rural main health centres or health sub centres established in the area.
2.5. There were difficulties in putting the established district and sub-district health centres and midwives’ clinic-cum-quarters into functional operation because of the acute shortage of trained local staff and of the sudden “Malayanisation” of the medical and health services immediately after the country attained its independence. During this transition period, it was not surprising to find many of the constructed health centres without their full complement of staff. However, the Government had made great efforts to provide at least the minimum staff available for these rural health centres, such as hospital assistants, staff health nurses and auxiliary workers like assistant nurse, Division II midwives and public health overseers. The Government of Malaya also recruited doctors from India.
2.6. The Government encountered financial difficulties as a result of the economic recession in 1958-1959 and of the continuing administrative and financial burdens of the National Emergency.
- The Government explored the use of local materials for building these health centres and clinics-cum-quarters.
- For financial reasons, it was found necessary to revise the original standard plans of physical buildings for district and sub-district health centres and midwives’ clinic-cum-quarters. A review was also made on the functions and how the facilities of these centres could be utilised to the full. The original standard plans of physical buildings for these centres were reduced in size as well as cost of construction
- Many of the district and sub-district health centres were built in town areas and it was felt that the siting of future rural health centres and midwives’ clinic-cum-quarters had to be carefully considered. The basic guideline in the setting of main health centres was to build the centre at the periphery of existing district or general hospitals. A referral system and cooperative arrangements with the hospitals and other facilities were arranged. Similarly, the sub-centres and midwives’ clinic-cum-quarters were to be filled-peripherally and radially away from each other and from the main health centre, thus establishing a network of coordinated medical and health services for the rural areas.
2.7. The Government was able to implement about 25% of the Rural Development Programme. The Rural Health Plan fell short of the target set in the First Five-Year Plan, 1956-1960. At the end of 1960, there were 11 district health centre 8 health sub-centres and 26 midwives’ clime-cum-quarters constructed. The construction programme of physical buildings had not been geared with the training intake and output of professional and auxiliary personnel. In this respect, the time factor was important as it takes a longer period to train various types of health personnel than to build the physical buildings for these health centres and midwives’ clinic-cum-quarters.
2.8. However, the economic recession was short-lived and the national emergency was put to an end in July, 1960. These events enabled the Government to accelerate the tempo of implementing the rural health development programme.
- The Ministry of Rural Development was established in 1960 and the National Development Operation Room was organised in 1961 as the Government Centre for directing rural development plans including the Rural Health Services Scheme. The Government planning machinery at all levels of administration was strengthened and closer coordination between ministries and departments was established by the organisation of the National and Rural Development Council at federal level and of the State and District Rural Development Committees in each State. The planning of the Rural Health Units was coordinated in each State by the Chief Medical and Health Officer with the State Rural Development Committee while the Medical Officer of Health would coordinate with the District Rural Development Committee at each district level. At the village or “kampong” level, the Medical and Health Officer in charge of the Rural Health Unit or his representative would coordinate with the Village or “Kampong” Development Committee. These rural health centres and midwives’ clinic-cum-quarters were related to the existing medical and health facilities and to other services, such as, community centres, schools, playgrounds, etc., through the “RED BOOK” in the Rural Development Plans of the Ministry of National and Rural Development.
- The Ministry of Health is responsible for the overall planning. The available vital and health statistics and informational data were the basis upon which health planning and its objectives were framed. The health plans and activities were coordinated with the activities of the Government machinery for general and economic planning through the Economic Planning Unit of the Prime Minis ter’s Department. Officials have been assigned from time to time to represent the Ministry of Health in the general and economic planning activities. Close and frequent consultations are maintained through the Economic Planning Unit between the National Development Planning Committee and the Ministries and Departments. The Ministry of Health makes its representation when necessary or when called upon by the planning unit.
3. In pursuance of the Government’s declared policy to develop the rural areas, the country embarked on the Second Five-Year Social and Economic Development Plan, 1961-1965. Under the Rural Development Plan, the Ministry of Health had envisaged the expansion and development of integrated curative and preventive health services by establishing a network of 100 Rural Health Units to serve 5 million rural population. Each Rural Health Unit comprising of a Main Health Centre with an administrative block for the basic health staff, 4 health sub-centres, and 20 mid-wives’ clinic-cum-quarters, will cater to 50,000 rural population. With this goal in view, 100 main health centres. 400 health sub-centres and 2,000 midwives clinic-cum-quarters would have to be established. The Ministry of Health had planned to establish 37 main health centres, 148 health sub-centres and 652 midwives’ clinic-cum-quarters under the Second Five-Year Plan, 1961-1965. The Plan was also aimed to consolidate and develop the pro gramme undertaken during the First Five-Year Plan, 1956-1960.
(a) In the Second Five-Year Plan, 1961-1965, forty million dollars for Rural Health Development had been allocated. Estimated Cost of a Rural Health Unit –
Estimated Cost of a Rural Health Unit
(1) Total estimated capital expenditure $1,000,000
|Main Health Centres:
|Quarters for staff, garage, and storeroom
|Furniture and Equipment
|Health Sub-Centres (4 for each unit):
|Quarters for staff, garage, and storeroom
|Furniture and Equipment
|Total for (4)
|Midwives’ Clinic-cum-Quarters (20 for each unit)
|Furniture and Equipment
|Total for (20)
(2) Total Estimated Annual Recurrent Expenditures $335,000
|Main Health Centre
|Other Charges Annual Recurrent
|Health Sub-Centre (4 for each unit)
|Other Charges Annual Recurrent
The estimated costs of land and of construction work may vary from state to state according to accessibility and avail ability of materials within the area.
(b) There was no basic change in the plan except that the functional organisation which would be extended ultimately into all the areas of the country and would constitute as the outposts of an administrative and supervisory network of health organisation from the Ministry of Health to the periphery, would be the Rural Health Unit.
(c) The idea behind the Rural Health Services Scheme was to provide a working baselike the health centres and midwives’ clinic and defined operational areas of “kampongs” or villages and homes for the teams of rural health workers.
(d) The family units would be_fue focal point of personal health approach in meeting the needs and problems of the rural people. The villages or “kampongs” and homes would be site of operational area for field work in community health a roach to raise the standard of health in the rural areas.
(e) Under this health scheme, it was envisaged to provide and develop the rural health staff of these health units as the frontline rural or community health workers rendering both educational and technical services to the people. For these services to be effective and maintained, the rural health workers would have the basic technical knowledge and skill to apply such knowledge for the benefit of the people to be served. The villages or “kampongs” covered by the rural health units would be the nucleus o a rural health development area which would also be a part of or within the development area for other services such as education, agriculture, etc. The front-line rural health staff (medical and health officer, dental officer, public health nurse, public health inspector, hospital assistant, dental nurses, assistant nurses, staff midwives, public health overseers and other auxiliary workers) would effectively serve as rallying points for rural health development approach.
(f) To meet the health priority needs and problems of the rural masses, the following programme of integrated curative and preventive health services would be organised and gradually developed at these main health centres and health subcentres: maternal and child care including domiciliary midwifery and public health nursing; medical care and dispensary services; mental hygiene and improvement of nutritional status of mothers and children; health education and community organisation; rural environmental sanitation; control of communicable diseases; school health services; dental health; maintenance of proper health records and collection of vital and health statistics and informational data necessary for evaluation of health services .rendered to the rural families.
3.1. Underlying the entire medical and health development programme was the expansion and acceleration of medical education and training. Among others, the Ministry of Health laid emphasis on organisation, expansion and improvement of public health training programmes and facilities. The facilities and training at the Rural Health Training School, Jitra, Kedah, was expanded to accommodate 54 trainees. A similar Rural Health Training School for 24 trainees was established and organised at Rembau, Negri Sembilan and was put into operation in early 1966. The training courses for public health nurses and public health inspectors were transferred to the newly constructed Public Health Institute for integration and consolidation under one roof and directorship. Training courses of various types would be organised and offered at this Institute.
(a) There was acute shortage of doctors to staff the rural health centres and very few liked to join the health services.
- Doctors were recruited from Korea, Philippines and from other countries.
- Doctors holding the Diploma of Public Health were given special monthly allowance of $350. Those gazetted as Medical Officers of Health without Diploma of Public Health were given monthly allowance of $175.
(b) Training intake for all categories of medical and health workers was doubled and accelerated.
3.2. In the light of the needs arising from the rapid expansion of health services and from advanced knowledge, techniques and methods in public health administration, the organisational structure of the Ministry of Health was strengthened by establishing additional posts for professional officers to head the newly created divisions.
(a) These officers would be responsible for planning programmes, formulating broad policies. and establishing uniform practices and processes for their respective fields. for example, maternal and child including domiciliary midwifery and school health; health education and community health organisation; environmental health, communicable disease control; etc. These in turn would be the foundation and basis of operation and supervision of these services at the state, district and rural health unit levels of health organisation of the Ministry of Health. Respective heads of Division will coordinate their programmes and technical policies accordingly with each other and with other departments with related programmes.
(b) In view of the demands by the Rural Health Development programmes and the rapid expansion of the medical and health services,
- a Development Officer responsible for consolidating and co-ordinating the overall medical and health development plans from all the states was posted at the Ministry of Health in 1960;
- an External Liaison Officer responsible for the increasing requests for international assistance, like technical experts, tutorial assistance, fellowships, equipment and supplies, etc., was established in 1960;
- a Training Officer responsible for consolidating, coordinating and planning the overall training needs and personnel required for the expansion of medical and health services was established in late 1963; and
- a Senior Medical Records Officer was posted at the Ministry of Health to take charge of Records and Health Statistics.
(c) Planning and programming of health services are responsibilities of the Ministry of Health but the staff officials at the federal level of the Ministry of Health do not have executive functions. They are responsible for formulating technical policies, programmes and standards of procedures and techniques for their respective fields of specialities like, in public health nursing, maternal and child health care, health education, environmental health, etc.
(d) The Chief Medical and Health Officer of each State, consistent with the policies and objectives of the Central Government, through the Ministry of Health, plans, organizes, coordinates, directs, estimates the expenditures and executes medical and health programmes including the Rural Health Development Programmes. The plans and programmes are planned in consultation with the appropriate staff officers of the state, medical, health and dental services (State and Health Matrons, Principal Dental Officer, Senior Medical Officer of Health or Medical Officers of each District, Superintending Pharmaceutical Chemist and Development Officer) and in collaboration and coordination with the State Rural Development Committee.
- Every State is divided into administrative health districts. The Medical Officer of Health in charge of a District Health Office is responsible to the Chief Medical and Health Officer or to the Deputy Chief Medical and Health Officer in the State. He is responsible for the total health programme in his district with assistance from technical staff like, the public health sisters, public health inspectors, and hospital assistants. Dental Officers provide dental services to the areas within the district including services at the Rural Health Centres. The Medical Officer of Health with respective staff officers concerned have administrative and supervisory functions over their respective counterparts at the Rural Health Units.
- The Medical and Health Officer in charge of a Rural Health Unit would be the team leader of both basic and auxiliary health staff and the coordinator of the rural health services.
(e) All State plans and programmes are submitted to the Ministry of Health for review, processing and consolidation. Each State medical and health plans are reviewed in consultation with respective Chief Medical and Health Officer before the overall plans are submitted to Government for financial allocations and approval.
3.3. In the Second Five-Year Social and Economic Development Plan, 1961-1965, 39 main health centres, 122 health sub-centres and 643 midwives’ clinc-cum-quarters were established and put
into operation. The basic health services are gradually being developed at these health centres and clinics.
(a) The staffing pattern of these Rural Health Units had been very much improved since end of 1965. Of the 39 main centres, 23 have been provided with medical and health officers who also periodically visit the sub-centres linked to the main health centre. The other main health centres and sub-centres are visited by either a medical officer of the district hospital or by a medical officer of health of the district health office. Korean doctors with public health training were posted either at the district health office or main health centre. The Government would be recruiting doctors from the Philippines and the United Arab Republic.
(b) The Rural Health Units are operating with either minimum staff or full complement of staff as provided in the “Organisation of Rural Health Services in Malaya”, 1963. However, there are a number of health staff without public health training. There is a great need to accelerate and improve the training programmes for public health workers. Transport facilities are needed for mobility of the supervisory staff and of the front-line rural health workers. The field health staff would need transport in working in the villages and getting the participation of the rural people,
3.4. The National Health Council to the Ministry of Health was established in 1963 and several committees to deal with special problems or with certain technical phases of the health programme were organised.
3.5. The World Health Organisation provided technical assistance in developing projects for training health personnel and for organising the rural health services.
(a) At Jitra, a Rural Health Training School and a demonstration and training health centre (WHO/UNICEF assisted project) was established for the primary purpose of pre paring auxilfary7iealth personnel in. rural or community health work. A similar training school and demonstration and training health centre is being organised in Rembau.
(b) WHO Medical Officer, Malaya-24 Project, bad assisted in formulating policies on the organisation and administration of rural health services and in improving training and services for the promotion of health and prevention of diseases.
(c) A WHO Project Team, Malaysia–35, composed of WHO Medical Officer, Sanitarian and Public Health Nurse, had been giving assistance in strengthening the organisation and operation of rural health services and health personnel training. Emphasis had been on the development of the most important basic health services, such as, rural environmental sanitation, public health nursing, maternal and child care including domiciliary midwifery, and training programmes which will best meet the needs of the Rural Health Service Scheme.
(d) WHO Fellowships had also been given to Officers who are holding responsible positions to enable them to renew their scientific knowledge and contacts in their respective fields and to give opportunities in keeping up with the modem developments in public health methods and techniques and in public health administration.
3.6. In the past, UNICEF extended material assistance in equipping the expanding maternal and child welfare facilities and training schools. With integration of maternal and child health services with other fields of basic health services at the main health centres, health subcentres and midwives’ clinics, UNICEF had increased its assistance to the Rural Health Services Scheme to include equipment, supplies and transports for dental health service, improvement of rural environmental sanitation-kits, water pumps and tools through Pilot Projects, health education, and other related needs such as refrigerators and books for training institutions. The Government requested continuing assistance from UNICEF in equipping the main health centres, health sub-centres and midwives’ clinic-cum quarters and training institutions to be constructed under the Five-Year Social and Economic Plans.
4. The Third Five-Year £Jan called the “First Malaysia Plan” l9.66-J970, was envisaged upon the birth of Malaysia in 1963 which included the States of Sabah, Sarawak and Singapore. However, Singapore became a Republic upon its separation in 1965. Due to financial burdens of confrontation by Indonesia, the expenditures for the development programmes had been cut down. The Rural Health Development Programme provided the construction of 60 sub-centres and 450 midwives’ clinic-cum quarters and would deal mainly with arrears of maintenance of and improvements to existing installations-mainly hospitals. With the cutting down of construction programme for rural health centres, the Ministry of Health would consolidate and develop the rural health services at those established rural health centres and midwives’ clinic-cum-quarters. Public health being an integral part of the social and economic development of the country, the pattern of public health administration has changed to emphasize positive approach in the organization of rural health services. Such positive approach is to create healthy environment and to educate the rural people for active participation in the improvement of their health conditions. The community health development approach would have to be applied by the technical service staff in the process of extending health services to the rural masses.
INTEGRATION OF SPECIAL PROGRAMMES
Programmes for special diseases such as yaws, malaria, leprosy, filariasis and other prevalent communicable diseases would, in due time, be integrated into the activities of the rural health staff concerned. Integration can be made possible by either:
(a) the special team for the control programme can be additional staff at the rural health centres and would carry on surveillance and control measures in areas where the disease had been prevalent; or
(b) the rural health staff of the rural health units would coordinate with the special team and would carry on the surveillance and control measures in areas where the incidence of disease had already been under control.
The Rural Health Units are serving as detector centres for these diseases by early recognition, prompt treatment or referral to the agency responsible for the special control programme, institution of hygienic measures for the control of the disease, investigation and follow-up of cases and contacts and giving of immunization such as BCG, triple antigen, etc. The yaws campaign had now developed where the rural health staff is carrying on the work of surveillance of cases in those areas where the disease had been under control.
STUDIES AND PILOT PROJECTS
1. Substantial reduction in incidence of many of the diseases which are attributable to defective environment in the rural areas could be attained by improving the environmental sanitation, even if confined to providing safe water supply and proper disposal of excreta and refuse. Recognising these problems in the rural areas, the Ministry of Health has decided to carry out pilot projects in improving_the environmental sanitary conditions in each state before launching a nationwide campaign. The purposes of the pilot projects are:
(a) to gather experiences and informational data on the most economical and effective methods of conducting sanitation campaigns in the rural areas;
(b) to gain knowledge on the technical aspects of well and latrine constructions, installations and maintenance of these facilities; and
(c) to obtain the participation of the people in planning and carrying out activities for solving sanitation problems.
As an initial step before launching the pilot projects in each state, public health inspectors and public health overseers involved in the project areas selected were given a training course. Three courses bad already been held, one at the Rural Health Training School, Rembau, in August, 1966, the other two courses at Kuala Trengganu and at the Rural Health Training School, Jitra, respectively in September, 1966.
2. The Government, through the Food and Nutrition Committee of the National Health Council, is planning an Applied Nutrition Project with the following objectives:
(a) to demonstrate how the various resources and agencies can be co-ordinated and their activities integrated with community participation to improve their nutritional status under “Gerakan Maju”;
(b) to serve as a training field in Applied Nutrition for various community extension workers and leaders; and
(c) to prepare for an expanded Applied Nutrition Programme based on the experience gained in the project.
The plan of operation for this Applied Nutrition Project will be submitted to the Ministry of National and Rural Development which will be the coordinating body for this project. A coordinated field. services programme which will operate in a limited area and through health services, schools, agriculture and co operative services, and rural development programme is being envisaged in this project. The selection of the pilot area for this Applied Nutrition Project is still under consideration. Further meetings are being held to determine the location and to finalise the plan of operation.
3. Studies on the activities of various categories of health nursing staff..at main health centres and health sub-centres are being carried out. These studies would provide some baseline to ensure the maximum contribution of health nursing personnel in strengthening the rural health services.
4. Plans to develop school health service as an integral part of the rural health services and as a continuing activity and programme of the rural health staff has been envisaged by the Ministry of Health. In many of the rural health centres where there is full complement of health staff, school health service has been started as a pilot project. However, to develop a school health programme of which school health service is a part, coordination and colla boration with the school authorities and participation of parents and the community as a whole are essential. A joint School Health Committee between the health and education ministries would have to be established. There are some aspects of the school health programme which would require coordination with other departments and voluntary organisations and community action and participation.
5. The Ministry of Health feels that pilot projects are most effective if they are associated with training activities. Hence the Ministry plans to carry out pilot projects and action research in the demonstration areas of the Rural Health Training Schools at Jitra, Kedah, and at Rembau, Negri Sembilan, and at the Public Health Institute, Kuala Lumpur. With this in view, there will be increasing numbers of trainees coming from all over the country who will gain experience at these pilot projects and who will eventually use these experiences for expansion to other areas. The newly created Public Health Institute is now planning to take over the technical supervision of the two Rural Health Training Schools and demonstration and training health centres at Jitra and Rembau with a view to coordinate action research aimed in strengthening the rural health services with special emphasis in improving methods of getting community participation.
For the rural community health programme to succeed, it is necessary to have properly selected and adequately .trained community health workers. These health workers should familiarise themselves with the principles and techniques of working with groups and of community development. The Ministry of Health has made provisions in this respect, by establishing the rural health training schools and demonstration centres at Jitra and at Rembau and the Public Health Institute at Kuala Lumpur. ln the theoretical and practical instructions, topics on health education methodology and community organisation, group work and the principles and techniques of community development had been included in the training courses provided at these institutions. This is important since in rendering their services. these front line workers come into intimate contact with all sections of the community and this brings them in positions wherein they can exert the desired influence on the community. The rural health services had been planned on practical basis and rendered by personnel trained to do the job. Properly trained and supervised health personnel are necessary to apply the modern technical knowledge of preventive and curative services and the principles and techniques of community development. The most effective method of promoting the people’s interest and gaining their confidence is the provision of sound health services directed to meet their basic needs. Unless health services produce tangible results, it will be hard to sustain the community’s interest and confidence in the rural health staff. The principle that community health programme should “start with people as they are and the community as it is” can be applied anywhere.
l. There are various ways of evaluating the operational progress achieved in improving the standard of health of the people, depending on the types of services being provided and on the stated objectives. Evaluation of development plans would be done at frequent intervals by measuring performance against the objectives set in the plans. This would include the assessment of the organisational and administrative aspects of the services as well as an appraisal of the operational activities and progress of the programme. Evaluation can be performed to measure:
(3) adequacy of performance; and
It is important to study the total impact of health programmes on the rural community and to note the great diversity of ways and means of rendering health services to the people and the ways the people participate, react and accept the responsibility in improving their own health standard. Evaluation could be enormously helpful in adjusting programmes, changing priorities, balancing efforts of the Government and the people, and making it possible to curtail unproductive activity.
2. The Ministry of Health is continuously laying stress on the effectiveness of the health services provided to the people. In its effort in evaluating the effectiveness of the rural health services, it was felt that a sound practical system of recording the work done and the results obtained was necessary. The Ministry of Health has therefore designed booklets for recording general information and statistical data on the work load and accomplishments of the rural health staff of ea h main health centre, sub-centre and midwife’s clinic and on the state of health of the people and community as a whole. This information and statistical data when properly utilized, collected, compiled and analysed can be used as a means of evaluation of the rural health pro grammes. The Booklets which were introduced early this year for the use of the rural health units would be an important administrative process to effective teamwork and coordination among the rural health staff. After a period of pre-testing the contents and formats, these would be reviewed to provide the necessary information and statistical data for evaluation purposes. To improve recording and reporting system at the health centres. the machinery and facilities for this system are necessary, such as, filing cabinets, systematic and organised record forms, clerk or record clerks, etc. The Ministry of Health has sought UNICEF assistance for providing equipment necessary for establishing an organised system of recording and reporting.