Multidisciplinary public health: Leading from the front?

Career Paths of Public Health Medicine Specialists in South Africa

Public health (PH) skills are core to building responsive and appropriate health systems, and PH personnel including medical specialists are embedded in many countries' health systems. In South Africa, the medical specialty in PH, Public Health Medicine (PHM), has existed for over 40 years. Four years of accredited training plus success in a single national exit exam allows specialist registration with the Health Professions Council of South Africa (HPCSA). However, there are few posts designated specifically for PHM specialists in SA's health system. In view of uncertain roles, this research was designed to determine specialists' career paths, their work, job satisfaction, and perspectives on the future of the specialty. We combined three databases to generate the study population and invited all specialists to participate in an online or hard-copy survey. We found that in 2010, PHM was a small specialty of less 200 physicians. Of the 151 contactable, eligible physicians, 55.6% completed the questionnaire. Participants represented an aging group (median age = 49) of specialists and recent graduates were increasingly women. They largely worked in academic institutions (as managers, teachers, and researchers) and in the public sector health system; were motivated by a sense of social justice and their training was formative, exposing them to work settings which they later entered; were largely highly satisfied at work, but many worked in non-specialist positions. Indeed, one fifth had not registered with the HPCSA as specialists. They were concerned about the specialty's poor visibility and identity, but did not see other PH professionals as a threat. They believed that the specialty should refine its competencies, demonstrate its value and advocate for service positions at all levels of the public sector health service. PHM has a contribution to make—reorienting services to protect communities, preventing ill health, analyzing disease burdens locally, identifying innovations in a resource-constrained health service, largely preoccupied with curative care services.

Stakeholders' perspectives on Public Health Medicine in South Africa

South Africa (SA) is reforming its health system in preparation for an anticipated national health insurance (NHI) scheme that aims to improve the delivery of affordable, equitable, accessible health care. Public health (PH) language is explicit in the policy and skilled PH professionals would be expected to play a key role in its implementation. In South Africa, training of doctors as Public Health Medicine (PHM) specialists is funded by the state, yet there are few positions for PHM specialists in the health services. We explored stakeholders' perspectives about this absence, and their views on PHM specialist' roles and contribution in an era of health reform. A qualitative study was conducted in 2012-13, using in-depth interviews with thematic analysis, which elicited perspectives of 31 key stakeholders nationally reflecting diverse employer and institutional backgrounds. While some were surprised by the absence of PH professionals in SA's health system, most agreed the reason was due to factors internal to the profession, such as its low profile and uncertain identity. External factors such as legislation and political preferences for health managers impacted on the employment of PH professionals. However, given the competencies required to implement an ambitious restructuring of the health sector, all believed that PH and PHM personnel were vital. In view of the health system's dominant curative orientation, embedding PH personnel in the services should ensure that health protection, promotion and prevention strategies will inform health priorities. This study, the first known from a low and middle-income country, contributes to the international literature about the identity and roles of PHM physicians, who are versatile professionals with broad skills-sets. In SA, through consultation with health sector employers about potential roles, curricular redesign and trainee recruitment, PHM can graduate fit-for-purpose specialists to work in a range of institutions to address health system reform.

Exploring the multidisciplinary extent of public health career structures in 12 countries: an exploratory mapping

Background

While much is known about multidisciplinary public health (MDPH) professional practice in the UK which developed particularly in the 1990s, little is known about it in other settings especially low and middle-income countries (LMICs). This study reports on findings of a mapping review of public health career structures and an examination of how multidisciplinary they are in 12 countries.

Methods

A 12-element template was used to collect data from relevant websites and key informants with public health experience in the 12 countries.

Results

We found that while countries had similarities such as having MDPH professional organizations, there were differences in terms of public health specialty training programmes and openness of senior public health posts at various administrative levels to non-medical professionals.

Conclusion

We conclude that there still gaps in MDPH career structures internationally. While this study provides preliminary knowledge on the subject, we recommend further research to inform debates and policies in MDPH professional practice especially in LMICs.

Through the glass ceiling—and back again: The experiences of two of the first non-medical directors of public health in England

In 2001, the English Department of Health announced a radical re-organisation of the NHS under the banner of 'shifting the balance of power'. As part of this re-organisation health authorities were abolished and the main NHS public health responsibilities devolved to the new primary care trusts (PCTs) from April 2002. Following several years of campaigning by the Multidisciplinary Public Health Forum (MPHF), in November 2001 the Acting Minister for Public Health, Lord Hunt, announced that PCT director of public health (DPH) posts would be open to 'suitably qualified' candidates from any discipline. From April 2002 a number of new DsPH from backgrounds other than medicine were appointed. This paper reports on the experiences of two such DsPH who shared a commitment to multidisciplinary public health, but who did not wholly share the objectives of the MPHF. We place the opening of PCT DPH posts in the context of tensions within NHS public health between a focus on health services versus the wider determinants of health, and the development of multidisciplinary public health. The paper reflects on both the degree of change this opening represented and the limitations and tensions such appointments exposed.

Fringe benefits? The impact of the Multidisciplinary Public Health Forum in the UK outside of England

The impact of the UK Multidisciplinary Public Health Forum in developing the public health workforce has been the subject of some discussion. However, much of the work to date has focused on the impact of the Forum in the English context. This paper uses the same techniques used to examine the impact of the Forum in England to describe the situation in Scotland. The key themes that emerge are that the impact of the Multidisciplinary Public Health Forum in Scotland was marginal and that a multi-professional approach was the more likely route of development. The adoption of regulatory policy by the UK Government in Westminster had the effect of producing a multidisciplinary approach in Scotland. The relationship of these findings to the experiences of Wales and Northern Ireland is discussed.