"Social Influences on the Health and Well-being of Children & Young People: Challenges for Public Health" Terlebih dahulu saya mengucapkan terima kasih kepada ASLI kerana menjemput saya untuk berucap dan seterusnya merasmikan Persidangan Kesihatan Peringkat Kebangsaan ini. Saya berasa syukur ke hadrat Allah S.W.T. kerana sejak negara kita merdeka Kerajaan dapat memajukan negara dengan pesat. Semua pihak termasuk kanak-kanak dan golongan muda- mudi turut terlibat dalam pembangunan negara. Kerajaan bangga golongan muda-mudi di negara ini dapat hidup aman damai, sihat dan sentiasa berpandangan positif dan berkeyakinan bahawa hak dan kehidupan mereka boleh diubah sekiranya mereka berusaha dan diberi peluang memajukan diri mereka.

2. I would like to begin by congratulating all those who have contributed to organising this conference, and extending my own warm welcome to all the participants at the Conference here this morning.

3. Before I go into the topic of my speech here today, allow me to say a few words about the health care system of the country. Malaysia has a comprehensive system of health care ranging from primary to secondary and tertiary care with an effective in built referral system in the public sector. The services cover promotive, preventive, curative and rehabilitative health care. There is universal access to primary, secondary and tertiary care so no one is denied health care in the public sector. The World Development Report 1993 recognises us as one of the few countries in which public spending on health is biased towards the poor, with the lower income groups receiving a larger share of public subsidies. 95 percent of the population in Peninsular Malaysia are within five kilometres reach of basic health care services while in East Malaysia nearly 75 percent of the population have the same access. 90 percent of infants have received immunisation against diseases like diphtheria, poliomyelitis and tetanus.

4. The people have also become more affluent and their expectations of the quality of healthcare that they want the government to provide are continuously rising. There has also been a proliferation of private healthcare facilities of a five star nature and this to the public has become a benchmark for comparison. The growth of the private sector with its higher wages and other perks has led to a brain drain of experienced staff from the government healthcare system and this haemorrhage continues. New technology is constantly being introduced and this increases the pressure on costs especially as this technology is expensive and is often subjected to inappropriate use, either provider driven or patient driven. At the same time there are pressures of changing demography, such as ageing of the population and the rural urban migration, all of which leads to a changing pattern of disease with a shift to chronic and debilitating diseases which are voracious consumers of health care resources.

5. World wide there is growing concern over escalating health care costs and Malaysia is no exception. The escalating health care costs is contributed in part by advances in medical technologies; aging population, changing patterns of disease from easily treatable infectious diseases in the past to more chronic conditions which consumes a high proportion of our health resources and many other factors. Cost is an important consideration in planning and development of services under the Ministry of Health to ensure that the most appropriate technologies are adopted to provide a comprehensive range of medical services that is of high quality and at a cost that is affordable.

6. It has been said that sustainable urban development is one of the most pressing challenges facing the human community in the 21st Century. For while the world's cities are becoming hubs of dynamism, change and opportunity, they are also becoming platforms for exploitation, unemployment and disease. All of this has profound implications for the survival and development of the world's children, who represent at least half of the nearly three billion people who live on the equivalent of two dollar a day or less.

Slums - also known as pre-urban squatter settlements - are growing rapidly in the developing world, their populations swelled by rural migrants who are arriving in such numbers that most overall city populations are doubling every 10 to 15 years. They are home to some 800 million people, or nearly 40 percent of all city residents.

7. The overcrowding, poor housing and lack of adequate sanitation make these areas ideal staging areas for epidemics of child killers like diarrhoea, measles and acute respiratory infections. The lack of meaningful employment and resultant poverty, especially for women, is a boon for commercial sex, which fuels the spread of sexually transmitted infections - especially HIV/AIDS.

8. In many urban areas, HIV/AIDS, poverty and overcrowding are fuelling a resurgence of tuberculosis. Indoor air pollution from cooking fires is a danger to child health, while tobacco products - aggressively marketed in the developing world by multinational corporations - is a factor in increased rates of pneumonia in children. And this is quite apart from the rising toll that tobacco is taking on adults, many of whom begin smoking in childhood.

9. Slum conditions are also behind the growing worldwide population of children, who lead Hobbesian lives in the streets, begging, stealing or engaging in commercial sex. The sheer scale of all of this feeds a sense of hopelessness among impoverished urban children and their families - and because it inspires inaction, that hopelessness is the greatest challenge to addressing their plight.

10. But if there is just one message that I would leave you with today, it is that there is hope. We can make good on the national commitment to give every child a better future - but only if that hope is translated into a vision - a vision implemented by clear planning, determination, hard work and resources, however modest. That vision must include, first and foremost, land tenure, based on sound principles of urban planning. When poor people are given title to a piece of land, they will build better housing. This should decrease the recourse to lands prone to flooding or mudslides. Safe water - and a connection to a sewer - can then be provided on a cost-recovery basis through metering.

11. Access to electricity will mean better light for homework at night, better access to information through radio and TV, and less risk of burns for children. Safe places to play in fresh air and sunlight are also important. A soccer field, a few benches, some trees and a plaza can transform a slum. These may seem like simple measures, but we know from experience that they can have an immediate and profound impact on child health. And better child health outcomes will also result when there is access to information, education and communication about family planning.

12. If we are to address the challenge of urbanisation, it is crucial that national and municipal governments, civil society and development agencies fulfil their commitment to increase the number of health centres - centres that will help the world move toward universal health coverage, using high impact, low-cost programmes like immunisation, provision of Vitamin A supplements and promotion of breast- feeding.

13. The groundwork for ensuring the health and well-being of children was laid in the 1950s, when the country first started the maternal and child health clinics which had helped place health issues firmly on the political and social agenda, cultivating ownership by mayors and governors, parliamentarians and civil society activists, the media and the academia.

14. Diarrhoea and a host of vaccine-preventable diseases were targeted to demonstrate that dramatic progress could be made in promoting child survival. Millions of lives were saved with the low-cost, high-impact techniques of oral dehydration therapy (ORT) and childhood immunisation. These interventions applied and elevated the concept of social mobilisation as a powerful tool to promote health.

15. Inverting the motto of Health for All to ALL for Health, the child survival and development revolution saw everyone, from film stars to schoolteachers, heads of religious organisations to heads of states, actively involved in promoting ORT, immunisation and other health and nutrition interventions.

16. Few social programmes offer greater long-term benefits for Malaysian society than guarantees good health care for all infants and toddlers. We realise the return on that investment when fewer children suffer from preventable illnesses and disabilities, when fewer parents bear the burden of caring for sick children and paying their medical bills, when more healthy children and adolescents succeed in school and, in time, form a more productive workforce and become better parents. We don't have to guess about the benefits of early health care; indeed, in no other area of social policy can costs and benefits be calculated so precisely. For example, every dollar spent on childhood immunisations saves ten dollars in later medical costs.

17. Being healthy also means being safe. At present, many infants and toddlers are not safe. Some grow up in neighbourhoods where a walk to the grocery store or an afternoon in the playground may be fraught with danger. Some spend long stretches, while their parents work, in substandard child care, under the supervision of underpaid, distracted babysitters, or in the care of brothers or sisters who themselves need more adult attention. And too many are at risk even when cared for by their own parents: some may suffer neglect or outright abuse; others may have parents who do not realise that their practices, or the setting they've provided, are unsafe.

18. To ensure good health and protection to our youngest children, this nation must: Provide needed health care services for all infants and toddlers; Protect infants and toddlers from injury and promote their health; and Create safe environments for infants and toddlers.

19. The supply of health professionals and the quality of child health care vary significantly by community: the most inadequate prenatal and child health services are found in low-income, minority, and transient communities. As a result, our poorest communities are plagued by high rates of infant mortality, low-birth weight babies, communicable childhood diseases, and child abuse. Children growing up in poverty suffer from higher rates of malnutrition and anaemia than do other children. Many of the tragedies represented by these statistics are preventable.

20. Children in poverty are not alone in receiving inadequate health care; nearly 13 percent of America's children do not have access to the health care services they need to grow up healthily. In 1992, 8.4 million children lacked access to health care services because they had no insurance and millions more were insured for only part of the year. Most children rely on working parents for health care coverage, yet nearly 80 percent of uninsured children are dependents of working parents. We in Malaysia do not want such things to happen to our children. We should seek to ensure that the promotion of child health should encompass: Health care services for all children must be comprehensive, preventive, and primary. Children who have chronic or disabling conditions need, in addition, specially designed services and support. Comprehensive services include parental education and counselling. Access to health care must be ensured through services such as transportation to health facilities and translators who can speak with parents and children in their own language.

21. There are two elements that would go farthest toward ensuring that children under three receive needed health care services. First, pregnant women, infants, and toddlers must be explicitly included in health care reform. Second, home visiting services should be available as part of comprehensive health services.

22. In handling the issue of health care reform, it should result in comprehensive health care services for all our nation's children. The task force recommends that pregnant women and all children under three be the first to be included in a universal system. Moreover, the task force agrees that the health care needs of infants and toddlers call for services that are broader in scope than those designed for older children and adults, and in certain instances they must be of greater intensity and duration than would be possible under a more general standard.

23. Young children need comprehensive health care because their needs differ markedly from those of older children and adults. Infants' and toddlers' unique needs arise from their developmental vulnerability and the degree to which they are dependent on others, on their parents and on social and governmental institutions for their health care.

24. Attempts at cost control may have unintended adverse effects on the quality of health care. The design or revision of a benefits package must take into account not only budgetary considerations and national priorities, but also scientific criteria for adequate health and medical care. Meaningful grievance procedures must enable consumers and providers to protest unfair practices or unintended consequences. To achieve this, consumers and clinicians must work with policymakers in defining what constitutes a child health care service.

25. Clearly, money is the main barrier between young children and the health services they require; but other non-financial barriers must also be surmounted. These include: Capacity shortages. Many communities do not have enough providers, especially paediatricians, family practitioners, and nurse practitioners.

Unfriendly services. Even parents who are motivated to seek out health services sometimes find them unfriendly and hard to access. Undervaluing of preventive services. Many parents who obtain health care when their children are sick are unlikely to use preventive services like well-child visits or immunisations, particularly when these services are not easily available. Lack of continuity. Many young children do not have a primary health care provider.

26. Other barriers include the violence, drugs, and social isolation found in some impoverished inner-city neighbourhoods conditions associated with low levels of health care. Expectant mothers in these neighbourhoods are far less likely to receive adequate prenatal care than those in more affluent locales; and preschool immunisation rates are also low in these areas. Already overstressed, these children and their families should not have to add inadequate health care to their list of everyday life problems.

27. Another promising way of improving health outcomes among families with young children is home visiting. For more than 50 years, home visiting conducted by the midwives and community nurses (Bidan & Jururawat Desa) has existed in the country as a strategy for delivering health care, information, and support services to pregnant woman and families with young children. Today, these home-visiting services should be strengthened and revisited as a preventive strategy.

28. The current practice of early hospital discharge after the birth of the newborn makes home visiting an attractive strategy during the first six weeks of life. In addition to providing education and advice, the home visitor can be an important link between the family and community services and supports. Some even offer voluntary home visiting services to all new parents and provide more intensive services to at-risk families with young children.

29. Especially effective are comprehensive prenatal and infant services, in which trained nurses or paraprofessionals visit unmarried, adolescent, uneducated, or low-income mothers and their children. These programmes have successfully encouraged expectant mothers to stop smoking, eat a balanced diet, use the proper nutrition supplementation programme, and seek childbirth education. In families that have been visited, the incidence of low- birth weight babies, child abuse and neglect, and childhood injuries has decreased. Home visiting programmes are also cost-effective.

30. Unintentional injuries remain the leading cause of death among children aged one to four. Children growing up in poverty are more likely to die from an unintentional injury than children from better-off families. While many childhood injuries do not result in death, they may result in disability or disfigurement and may compromise a child's future development, well-being and achievement. Because most of these injuries are preventable, the task force recommends new public strategies to reduce the incidence of unintentional injuries to young children. These strategies must include broad-based community efforts to encourage the use of child safety seats, fire alarms, window guards, and flame-retardant sleepwear, and to reduce the temperature of tap water in homes and child-care settings.

31. Promoting young children's health is a responsibility shared by parents, other caregivers, educators, the community, and health officials at all levels of government. But how can we best support parents' own efforts to promote their children's health? First, community leaders can identify what needs to be known by parents and others in the community. Second, programmes to teach health-promoting behaviours to parents can be started in accessible settings at convenient hours. Third, religious, civic, business, and other community organisations can communicate information about children's health, setting as their highest priority the good health of every neighbourhood child.

32. Although most research and public debate about violence have focused on school-aged children and adolescents, violence also affects pregnant women, infants, and toddlers. Women face the highest risk of violence by a male partner during their childbearing years, and most particularly during pregnancy. The abuse of pregnant women leads to serious risks for the infant, including low birth weight, birth defects, prematurely, and even such grave consequences as stillbirths and infant mortality.

33. There is no doubt that repeated exposure to violence threatens children's healthy physical, intellectual, and emotional development. Parents, too, are affected by a climate of violence; they often lose confidence and are so traumatised that they find it difficult to be emotionally responsive to their children. We must make a clear commitment to the right of all young children to grow up in safe homes and neighbourhoods. Parents would benefit from family-centred approaches to help them understand the profound effects of violence in the home and in the community on young children. Energy and resources must be directed toward preventing violence in children's lives and dealing with the damage that has already occurred. Hence we should recommend these interventions: Adopt family-centred approaches. The strongest buffer for young children living in dangerous environments is a supportive relationship with parents. Parent education and family support programmes can help parents understand their critical role in the lives of their children. Parents should have access to proven programmes that prevent child abuse and neglect and must be taught skills in non-violent conflict resolution. Supportive networks and individual counselling should be available to parents when necessary.

Initiate community-based efforts. Increased funding must be made available for community programmes that address violence prevention, such as partnerships between child and family services and law enforcement agencies. For maximum effectiveness programmes must be implemented locally. Such efforts convey to families that they are not alone--that society is committed to addressing violence in their communities.

34. We owe it to the children of the world and to the future of humanity to bring the benefit of our knowledge, expertise and commitment to the cause of Health for All.

Those who work in public health have the privilege - and the special obligation - to be in the vanguard of those promoting global public health. Human beings have the right to the highest attainable standards of health - and health is closely associated with human security, productivity, national development and international solidarity.

35. As public health specialists, you will need to work with partners and decision-makers far beyond hospitals, clinics or departments and ministries of health. To be truly effective you will need to mobilise support from sectors outside health.

36. I would also urge you, in addition to being medical practitioners and technical experts, to also be skillful brokers, negotiators, and diplomats in the pursuit of the Health for All goals - in short, builders of tomorrow's world - a world that is truly fit for children. As we ride the next wave of revolution in public health, I have no doubt that together, we will meet these expectations - and write a new chapter for better health in the 21st Century.

Thank you. May the Almighty guide us.

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