84-hour Work Week, Low Pay: Why Malaysia’s Doctors Are Leaving | Insight | Full Episode

Malaysia's Public Healthcare System Under Pressure: A Detailed Summary

Key Concepts:

• Doctor shortage in public hospitals
• Brain drain of medical professionals
• Contract vs. permanent doctor positions
• Medical graduate surplus and moratorum
• Aging population and increasing healthcare burden
• Specialist to population ratio
• Medical Amendment Bill
• Returning Expert Program (REP)
• Housemanship training
• Non-communicable diseases (NCDs) like diabetes and hypertension

The Crisis in Malaysia's Public Healthcare System

Malaysia's public healthcare system is facing a significant crisis due to a confluence of factors, leading to immense strain on medical professionals and impacting patient care. Haznolia Abdul Hamid's experience highlights the challenges patients face in navigating the system and obtaining timely diagnoses.

• Overburdened System: The public system is overburdened, with reports of crises in certain areas.
• Doctor Shortage: There's a growing shortage of doctors in public hospitals. In 2019, there were 6,134 housemen employed by the Ministry of Health, which fell to 3,271 in 2023 – a 50% drop in just a few years. The intake of doctors has dropped from around 5-6,000 eight or nine years ago to around 3,000.
• Staffing Issues: Emergency cases, falling recruitment, an exodus of doctors, and a growing patient load are contributing to the strain.
• Uneven Distribution: While the overall doctor-to-population ratio (2.4 doctors per 1,000 people in 2023, the second highest in Southeast Asia after Singapore) appears sufficient, doctors are concentrated in urban centers and wealthier states like Johor, Penang, and Selangor. States like Sabah, Sarawak, Pahang, and Kelantan face a significant discrepancy in doctor-to-population ratio.
• Specialist Shortage: The shortage is particularly acute for specialist doctors. Malaysia's population-to-specialist ratio is approximately four doctors for every 10,000 people, significantly lower than the OECD's recommended ratio of 14.3 specialists to 10,000 people. Only about 15% of doctors in the public sector are specialists. There are only 14 cardiothoracic surgeons nationwide.
• Long Waiting Times: Shortages lead to long waiting lists for treatment, as exemplified by Azmir Sherafhudin's year-long wait for eye surgery for diabetic retinopathy. Manisha waited hours at a public hospital and a week to see a specialist after a motorbike accident.
• Increased Patient Load: Patient visits to government hospitals and clinics reached approximately 77 million in 2022, a 4.5-fold increase since 2008, due to affordability.
• Nursing Shortage: There is also a shortage of nurses, with almost 7,000 unfilled nursing positions in 2023. The Ministry of Health projects a potential shortfall of almost 60% of the required nursing workforce by 2030.

Causes of the Doctor Shortage

Several factors have contributed to the current shortage, despite a past surplus of medical graduates.

• Overproduction of Graduates: In the 1990s, Malaysia had only three medical schools producing around 300 graduates annually. Driven by the ambition to achieve a doctor-to-population ratio of 1 to 400, the country expanded to over 30 medical schools, producing thousands of graduates.
• Moratorium on New Programs: By the 2010s, the government implemented a 5-year moratorium on new medical programs (extended in 2016) to regulate the number of graduates. The quota was set at 1550 students annually.
• Contract Doctor System: To absorb the oversupply, hospitals began hiring doctors on contract instead of offering permanent positions. This limited career progression, access to specialist training, and financial stability for doctors. Dr. Muhammad, who remained anonymous, waited a year for a housemanship position and was on contract for 7 years.
• Long Working Hours: Doctors in Malaysia work long hours, with some clocking as many as 84 hours a week. Lack of doctors leads to on-call duties stretching up to 33 hours, 8-10 times per month, and even 13-14 times per month in Sabah and Sarawak.
• Low Pay: The monthly pay scale for a grade UD43 doctor ranges from 3,611 to 10,560 ringgit (around $850 to $2,490 per month). The high cost of medical education (around 500,000 ringgit) makes it difficult for doctors to recoup their investment.
• Brain Drain: Many doctors are leaving for better pay and opportunities overseas. The World Bank estimates that Malaysia loses approximately 20% of its trained medical professionals annually since the late 1990s. Dr. Sed Ajmal moved to the UK in 2016 for a significantly higher salary and a sense of adventure. The Malaysian Medical Association estimates that over 5,000 Malaysian doctors have left the country in the past decade.

Government Efforts to Address the Crisis

The government has taken several steps to address the staffing shortage and improve the healthcare system.

• Medical Amendment Bill: Parliament passed the Medical Amendment Bill to boost the number of specialists.
• Absorption of Contract Doctors: In April 2022, the government announced that it would absorb almost 13,000 contract doctors into permanent positions over a period of 3 years. In 2023, nearly 4,300 contract doctors were made permanent, costing the government about 1.7 billion ringgit.
• Salary Increase: The government has implemented a 15% salary increase for all civil servants, including doctors, and a slight increase in on-call allowance.
• Returning Expert Program (REP): Talent Corp manages the REP, encouraging skilled Malaysians to return through tax incentives and rebates. Since 2011, Talent Corp has approved almost 7,000 returnee applications, but only 483 (7%) are in healthcare.
• Parallel Pathway for Specialists: The 2024 medical amendment bill allows a parallel pathway for specialist training conducted by the Ministry of Health.
• Increased Recognition of Specialist Qualifications: The Malaysia Medical Council has increased the number of recognized qualifications in cardiothoracic surgery and created a mechanism for recognizing qualifications from other countries.
• White Paper on Healthcare: In 2023, the Ministry of Health published a white paper to address the issues faced by the medical community, including proposals to increase fees for those with means and allow doctors in public hospitals to supplement their income through private practice.

Challenges and Future Considerations

Despite these efforts, significant challenges remain.

• Transparency in Permanent Post Offers: There is a need for a transparent and cohort-based system for offering permanent positions to contract doctors.
• Adequacy of Pay and Allowances: The salary increase and on-call allowance may not be sufficient to address the rising cost of living, especially for young doctors and families in cities.
• Certification Period for Specialists: The extended certification period for specialists, with lower pay, may discourage doctors from pursuing specialization.
• Aging Population and NCDs: Malaysia's rapidly aging population and increasing prevalence of non-communicable diseases (NCDs) like diabetes and hypertension will further strain the healthcare system. Over 53% of Malaysians are either overweight or obese, and one in five has diabetes.
• Funding the Healthcare System: The government needs to find sustainable ways to fund the healthcare system, considering the increasing number of sick patients and the need for better salaries and benefits for healthcare workers.

Conclusion

Malaysia's public healthcare system is at a critical juncture. While the government has taken steps to address the doctor shortage and improve the system, more comprehensive and sustainable solutions are needed. These include addressing the root causes of the brain drain, ensuring fair compensation and career progression for doctors, improving the health of the population, and finding innovative ways to fund the healthcare system. The future of Malaysia's healthcare system depends on the ability to attract and retain talented medical professionals and provide quality care to its aging population.