Unboxing The Malaysian Healthcare System Crises — Part 1

It is no surprise to anyone at this stage about the issues the Malaysian healthcare system faces. It’s no less surprising towards what the system would eventually evolve into, for better or worse. We have been talking about our health system for decades now. Recalling my days with the Malaysian Medics International, an international body run by Malaysian medical students, we have been discussing the same issues for the past 7-8 years. Our issues were never isolated compartments, they are interconnected, multifaceted on a background of chronic latent unspoken orthodoxes. Truth is, what is orthodox, what is the norm, what is the culture, and what is the acceptable standards were all foundational ideologies, repetitive behaviours or" “upbringing” that were laid by our forefathers. Change is difficult. Evolution seems impossible, at this stage.

While our health system has grown slowly over the years, not all departments or subsections of the health system mature with it. For example, you may have new hospitals and clinics up and running, but you don’t have the staffs to run it. You may want to offer subspecialty services, yet you don’t have enough sub specialists to run it long term or the equipment or medical devices to follow suit.

While a lot of current healthcare worker issues are interconnected, I supposed it is reasonable to start with the exponential increase in resignations of doctors over the years.

Part 1: The healthcare system and the issues with contact employments

1. More and more doctors are leaving or have left the Malaysian Healthcare System

From a personal standpoint: I completed my MBBS in November 2019, there were approximately 90 people in my cohort at the time of graduation. More than half had decided to remain in Malaysia to start their housemanship. The other half were offered an internship position in Australia. From 2021 to 2022, another half of those who remained also came to Australia to commence internship training the following year. I counted, from my cohort, only 7 remains in Malaysia by the start of 2023. The ones who initially stayed, completed their housemanship and received offers to work in Australia as a resident.

Of course, there is no denying that having studied in Monash gives us the privilege of having direct access to employment in Australia. Many whom I know have also left during their MO-ship to sit for PLAB and/or AMC exams. Interestingly, mid last year when I got my offer to work as an RMO in Australia, I have also put up a thread in Twitter on applying to Australia. I got tremendous responses from the public, many have DM-ed me personally to enquire the pathways, the challenges and the route to specialisation, of which I shall have a separate blogpost on this.

2. Contract System - initial intentions, the truth, consequences

The Initial Intent

Employment contracts were introduced in late 2016 to resolve the glut of medical graduates waiting to start their housemanship. Were they successful? Yes and no. Yes, because waiting times did tremendously reduce from a year to 3 months (shortest I heard) all within the batches going into the workforce from 2021-2022. While the workforce expanded, it was only momentary. There happened to be a significant shortage of doctors towards the end of 2022 and the gravity was felt across all states. Factors to be considered were the post-covid syndrome that had driven doctors into resignation/retirement, unresolved contract system, the sudden hype of Hartal Doktor Kontrak and Code Black movement drew support and helped encouraged doctors to seek greener pastures. There were a lot of catalysts and catalysts in the making that had changed the course of junior doctors. The changing societal values and the beliefs that doctors should be better paid, with better human working hours were huge contributing factors.

The Truth

It was in 2019 then Health Minister, Dr. Dzulkefly Ahmad, announced that the government would no longer offer permanent positions to new doctors, the reason was to reduce the government's financial burden as permanent positions come with benefits such as pension and medical coverage.

Consequences

While many discussions and negotiations had taken place to address the concerns of contract doctors, a domino effect instead took place. With contract, the concerns then became about

• Job insecurity: Contracts can be terminated without notice.

• Limited career progression: Contract doctors have limited opportunities for career progression as they are not eligible for certain positions, promotions, or training opportunities. This had led to frustration and demotivation among doctors.

• Lack of benefits: Contract doctors in Malaysia do not receive the same benefits as permanent doctors, such as pension schemes and medical coverage.

• Discrimination: Contract doctors in Malaysia may also face discrimination in the workplace, as they are perceived as less valuable than permanent doctors. This discrimination leads to a negative work environment and affect the morale and mental health of contract doctors.

• Increased workload: Interestingly, since the inception of the contract system, the number of resignations have doubled if not tripled over the years. This translates to the current slate of doctors having to work longer hours and take on more responsibilities, which leads to burnout, exhaustion, and ultimately affecting the quality of patient care.

3. Efforts to retain contract doctors

At the peak of the contract crises, the government in 2020 to 2022 had made several efforts. These were

• Extension of Contract Period: In July 2020, the maximum contract period for contract doctors were extended from two years to four years.

• Special allowance: In June 2021, the government announced a special allowance of RM600 for contract doctors.

• Conversion to Permanent Positions: The government has announced that it will convert eligible contract doctors to permanent positions. In June 2021, the government announced that it would offer permanent positions to contract doctors who have served for a minimum of four years and meet other eligibility criteria.

• Career Progressions: Contract doctors are eligible to apply for specialist training under the Hadiah Latihan Persekutuan (HLP) sponsorship from January 28, 2022.

I wonder if these efforts succeeded or were they merely a sugarcoating to larger issue at stake.

4. Still unresolved issues with contract system

• What happens after the end of the maximum contract period?

• The lack of transparency on clear criteria, not to mention where is the policy document for doctors that are to be chosen to permanent positions?

• The selection of permanent and contract doctors for HLP?

• Loss of flexi allowance for medical officers would mean house officers are paid more than medical officers.

• What do we do with chronic medical officers?

Last Words

Doctors do their best for their patients. We work hard to get things done despite the patient load. At 5PM, the door closes for most departments and offices, we are unfortunately still at work. I guess in every design of a health system, shouldn’t the system favour the progression of doctors and all of its healthcare workers? Why design a system and prepare for it to fail?

I’ll be releasing Part 2 on working conditions of junior doctors soon and this will likely paint a detailed picture on the inner workings of the system.