1. INTRODUCTION

‘Health human resources’ is defined by the World Health Organization (WHO) as ‘all people engaged in actions whose primary intent is to enhance health’ [1]. This includes all people who contribute to a functional health system: those who provide health care directly and those (like public health professionals) who address the underlying health determinants, and others who support the overall effort in other ways [2]. Efficient public health services are key in minimizing diseases and increasing the standard of living. Public health is both multidisciplinary and interdisciplinary, as professional from different disciplines contribute their knowledge and skills for improving health [3]. There is a strong linkage between the health workforce and public health education as public health require intellectually rich and challenging workforce [4].

The initiative in public health traces back to 1872, when American Public Health Association was formed. The first independent School of Public Health (SPH) began in 1916 in the United States (US) [5]. The school was funded privately major by the Rockfeller philanthropies, which in early 20th century helped to define public health profession [6,7]. The London School of Hygiene and Tropical Medicine, the first SPH in the United Kingdom (UK) was founded in 1924 with support of Rockfeller philanthropies [8]. However, for much of the 19th century, there was no concept of organized public health. In 1960, the Hill-Rhodes Bill helped to renew interest in the public health in US [5].

At this time there was evolution in teaching methods also, with greater emphasis to problem-based learning especially in medical schools [9]. In 2008, the American Association of Colleges and Universities surveyed their membership and found that 167 institutions offered undergraduate majors, minors or concentrations in public health in US [10]. Frenk et al. [9] in 2010 estimated that there are about 450 schools of public health worldwide irrespective of departments and courses. According to European Association of Schools of Public Health, over 80 institutions in European region qualify as SPH [11]. In 2011, UK had 30 universities offering postgraduate qualification in public health [12], 36 universities offering Masters in different disciplines of public health such as nutrition, policy, the environment, research, management, nursing or communicable disease prevention [13], and the Universities’ Central Application Service shows more than 100 degrees that have a public health component [14].

In the Kingdom of Saudi Arabia (KSA), a royal decree from King Abdulaziz established the first public health department in Mecca in 1925, for providing free healthcare to the population and Hajj pilgrims [15]. The monitoring of healthcare services were done through series of hospitals and dispensaries. The second milestone achieved in the public health service in KSA was establishment of Ministry of Health (MOH) in 1950 under another decree. The MOH responsibility was to manage, plan health policies, supervise and monitor health services in private sector [16]. In KSA until 1980s, the main objective of MOH was to provide treatment for existing health problems for which expatriates were hired [16,17].

However, after the WHO General Assembly in 1978, in accordance to Alma-Ata declaration, the Saudi MOH began to develop preventive health service by adopting Primary Health Care (PHC) as one of its key health strategies [18]. The PHC focused on eight elements which included health education to prevent and control diseases, supply of safe water and basic sanitation, promotion of food supply and appropriate nutrition, maternal and child healthcare, immunization of children against major communicable diseases, appropriate treatment and providing of essential drugs [19].

In Saudi Arabia, pilgrims from over 160 countries gather to perform Hajj every year and in this period the risk of public health problems related to infectious diseases increase [20,21]. The Saudi government has taken a number of steps to improve the management of public health during Hajj but still outbreaks occur [22]. In 2009 there was a pandemic H1N1 influenza, the data analyses from Europe and the USA regarding the transmission dynamics of the virus estimated the basic reproduction number (R₀) of the virus to be 1.2–1.7, with higher estimates in Japan R₀ 2.3; (95% CI: 2.0–2.6) and in New Zealand R₀ 1.96; (95% CI: 1.80–2.5) [23]. The Saudi government was concerned that pilgrims suffering with or at risk of H1N1 influenza could result in increased basic reproduction number and secondary attack rates of H1N1 influenza during Hajj. Therefore, the Saudi government collaborated with WHO to plan strategies to control the 2009 H1N1 influenza pandemic from spreading during the Hajj season [24].

According to Saudi Ministry of Education (MOE) Annual Report 2018 [25], only 14 (46.7%) out of 30 universities provide bachelor courses in different disciplines of public health and five universities (16.67%) offers master’s degree in public health. Among the private universities and colleges, only four (13.3%) institutions provide bachelor course in public health and one (3.3%) offers a master’s degree in public health. However, since 2015 public health education shows an approximate increase of 3% and 6% in bachelor courses in public and private institutions respectively. The progress rate shows that it would take a long time to fulfil the need of competent public health workforce of the country.

Although some government and private institutions are offering courses related to public health in KSA, there continues to be challenges in producing competent public health professionals. One challenge is the lack of a standardized public health curriculum offered in all universities and educational institutions in the KSA. This is achievable through accreditation of educational institutions, which will lead to promote common standards in the course and training programs required for preparing competent public health workforce. Another challenge is to provide an appropriate and suitable practical exposure to the students so that they are able to justify the current trend of diseases [26].

Currently Saudi Arabia is experiencing outbreak of novel corona virus Middle East respiratory syndrome (MERS) caused by MERS-coronavirus (MERS-CoV) along with epidemiological and demographical transition, highlighting the importance of public health service and need of a competent public health workforce [26,27]. Moreover, the large size of the country and scattered population poses challenges to the health care service delivery, which include health facility planning and distribution of workforce. As public health is associated with the prevention and control of the diseases, it requires the local workforce for effective and efficient administration and management of public health programs. The government is working on strengthening the health care system, through eight elements of PHC approach. ‘Vision 2030’ is a long term plans in the KSA for strengthening the public sectors in the country that includes health, education, infrastructure, recreation and tourism thereby improving the economy of the country. The coordination between public health educational institutions and public health service organizations would help to achieve Vision 2030 goal of developing a sustainable public healthcare service in the KSA.

2. MATERIALS AND METHODS

In this descriptive cross-sectional research study, an exploratory mixed-method approach (qualitative and quantitative tools) was used to obtain information about public health education and workforce needs. Data were collected and analysed sequentially. The design begins with collection and analysis of qualitative data in the first phase, in order to develop Strength, Weakness, Opportunities and Threats (SWOT) model to identify the existing gaps in capacities. Based on the exploratory result from the first phase, the researchers conducted the second quantitative phase.

3. RESULTS

The baseline survey in 2015 revealed that there were 25 public universities, among them 11 (44%) offers undergraduate courses and four (16%) offers graduate courses in different disciplines of public health, while there were 26 private institutions, among them only two (7.7%) provides undergraduate course in public health. A review of the educational institutions carried out in 2018 to update the baseline data showed that there are presently 30 public and 30 private institutions. Out of 30 public institutions, 14 (46.7%) provides undergraduate courses and five (16.7%) offers graduate courses in public health and among the 30 private institutions, four (13.33%) offers undergraduate courses and one (3.33%) offers graduate course in public health. The distribution of sub-specialty of public health offered by public educational institutions in 2015 and 2018 is shown in Figure 1.

Figure 1

Distribution of sub-specialty of public health courses offered by public educational institution in 2015 and 2018.

3.4. SWOT Analysis of Qualitative Data Obtained in the First Phase

In SWOT analysis, the main strength of the organizations related to public health was found to be the willingness and commitment of ministries and other stakeholders to develop public health workforce programs. The weaknesses of the organizations found were shortage of resources and capacity to carry out public health workforce programs. The main opportunity for the organizations are the availability of global public health agency for partnership, but the lack of long-term commitment from the partner is the threat associated with it (Figure 2).

Figure 2

SWOT analysis of health related organizations Saudi Arabia.

4. DISCUSSION

The present study results showed that the health workers in Saudi Arabia health organizations have an associate degree or a bachelor degree in other than public health as qualifications. This reflects the lack of appropriate qualifications, skills and experience to deal with challenges that arise in the public health field. A movement toward defining criteria for professional competence has evolved recently because it was a common practice in the past to recruit or promote an individual within public health agencies based on outdated concepts of professional qualification eligibility, seniority or sometimes due to the political interference without paying attention to the adequacy of their knowledge, attitudes and skills in public health [2].

In the present study, all the public health-related organizations (100%) reported a need of specialized health workers with a qualification of at least master degree in public health sub-speciality epidemiology. This assessment of the educational needs of local public health organizations is an important step toward development of appropriate programs at the academic level to improve core competencies for public health professionals. Most of the western countries demand Master of Public Health degree, or its equivalent that is Master of Science in Public Health or Master of Health Sciences, as professional entry-level qualification for public health [28]. Master of Science in public health is programmed with emphasize to develop academically thought-provoking, student-centered learning, problem-solving and acquisition of skill necessary to practice public health. Therefore, recruitment of highly qualified employees and focus on continuing education for updating recent development will be sufficient for valuable and competent work [28]. The public health college and medical colleges must work together in an integrated model. This will help to generate the best possible healthcare workforce, develop innovative tools and approaches through research and eventually achieve the maximum potential for improving the public health.

Public health in the Middle Eastern countries is facing challenges both at the recruitment and retention of appropriate skills and expertise, in terms of both quality and quantity [29]. The present study found the same opinions from the administrative heads of the various health organizations. There is an overarching need to improve the ways to address health determinants; which requires cadres of professionals appropriately trained in public health measures [28]. The knowledge obtained from the SWOT analysis about the strengths and the opportunities can be utilized by the organization to develop the required workforce in public health-related departments. Moreover, the knowledge about the weaknesses will help the organization to improve the competency level of the workforce and the threats associated with the organization will guide the organization to prepare for adverse conditions in advance.

As per Saudi MOE Annual Report 2018, <50% government universities are providing bachelor courses in public health and <20% is providing master course [25]. The government of KSA is working hard on strengthening the health care system, through eight elements of PHC approach. To achieve Vision 2030 goal of developing a sustainable public healthcare services in the KSA, more public and private educational institutions should develop public health courses at undergraduate and graduate level, so that competent public healthcare workforce is produced.

The sub-specialty on high demand by organizations was epidemiology. As the KSA is at its initial phase of developing public health services, emphasis is placed on the need for epidemiological skills. The workforce with specialty in epidemiology have skills to enable priority settings, service planning and evaluation of outcomes, have ability to develop and implement health improvement programs, surveillance of non-communicable disease and competent in proving advice on arrange of public health issues to local organizations and the public [8]. At present, only three government universities and one private university is providing master course in epidemiology along with hospital administration. Only few institutions about 16.7% provide master course in public health with focus mainly on health administration. Therefore, approximately 92.7% of Health Science faculty members and 97.5% of students had the opinion that there is a need to establish educational programs in Saudi Universities related to Public Health. According to the 65.4% employed students, there is a need of public health specialty especially for the development of new public health departments.

In the present study, 50% of the public health related organizations showed interest in bridging course for their experienced employees. This finding is supported by 60.6% of the students working in health organizations who reported organization cares for their public health studies (Figure 3). This reflects the organizations in public health need their employees to be up-graded to stand the competency required in the field. This gives a positive signal for the academic institutions to introduce more post-graduate courses in the public health as the demand for this course is increasing. The online courses can be considered as promising new development for continuing education and bridging courses. The development programs as Training Programs in Epidemiology and Public Health Interventions Network and online courses should be viewed as a component of, or adjunct to, internal capacity development, but not as a replacement for it [28].

Figure 3

Sub-specialty in public health.

The demand for competent public health workforce will further increase as the government is focusing on enlarging the network of health services at PHC level to reach all the corners of the country [27]. Moreover, the government project of the Custodian of the Two Holy Mosques has planned to create around 2000 highly developed PHC center and also to upgrade the existing PHC center with well-equipped buildings, skilled and competent workforce, this will result in high demand of public health courses in the KSA [15].

According to the demand of organizations, students and faculty members, MPH program needs to focus on disciplinary areas such as epidemiology, infection control, food safety, and environmental and occupational health sciences. The MPH degree program development needs to emphasize on student centered learning, problem resolving and gaining of skills necessary to the practice of public health. The lack of resemblance between the taught and required could affect in public health workers being ill-prepared for the requirements of the real world [30]. Therefore, educational institutions should spread the health education by engaging the whole of society through community outreach programs.

The study from Hawai’i also assessed the needs for public health education in their state and reported lack of awareness about the MPH and MS programs in university of Hawai’i [31]. A study from Nepal reported there is a need for trained public health professionals in Nepal and educational institutions requires development of effective graduate programs [32]. The accreditation of the public health schools is an essential step toward the improvement and standardization of teaching programs as well as the establishment of competencies [33]. The affiliations of SPH to the local government will probably improve the balance between the needs of government and the autonomy of academic schools [33]. The public health schools should focus on research process of public health such as planning, evaluation, surveillance, investigation, and problem and pathway analyses. Building of well-organized public health educational institution requires structuring strong research and development skills among students, practitioners and faculty equally. The accreditation of SPH with local government will likely promote targeted research with appropriate funding.

Moreover, students who participated in this study had limited information about the place of work and public health-related organizations demand of sub-specialty in the KSA. The students Report convened by Welcome Trust highlighted that the health improvement can be achieved only when people are fully engaged in their own health and the health service is focused toward the promotion of good health and prevention of illness [34]. The youth should be updated about the scope of public health and encouraged to take admission in various public health courses, as it will elevate their general awareness of issues that affect individuals, families and communities. This will be a complementary social gain to promote health literacy, and development of a more active civil society in the health field.

5. CONCLUSION

The efforts and activities in public health in the KSA need more attention. Only few universities are providing master course in public health education, which shows that the local educational institutions are not keeping up with the demand for maintaining and improving the public health workforce. The work of public health professionals is important because public health initiatives affect people every day in every part of the world. There is a shortage of expertise in the public health organizations and there is a need for development of more public health schools in the KSA. The establishment of public health courses especially in the field of epidemiology at undergraduate and graduate level will help in the development of efficient and competent public health workforce.

CONFLICTS OF INTEREST

The authors declare they have no conflicts of interest.

AUTHORS’ CONTRIBUTION

MAM contributed in data curation, investigation, project administration, software and supervision. NBJ contributed in formal analysis. MAM and NBJ contributed in resources and writing (original draft). AMEE, MT, SC, AH and FEME contributed in validation and visualization. All authors contributed in methodology and writing (review and editing).