AFTER the Covid-19 crisis, from 2020 to 2022, Malaysia’s public healthcare system saw a massive exodus of doctors, nurses and healthcare staff at all levels.
This chronic human resource shortage has created a vicious cycle, with increasing numbers of people seeking care in public hospitals’ emergency and trauma departments, as well as outpatient services, resulting in overcrowded waiting rooms in government health clinics (Klinik Kesihatan).
Despite the growing demand, multiple intakes and a steady supply of freash medical graduates, the availability of house officers (HOs) or doctors-in-training has significantly declined in recent years. This shortage, affecting most district and tertiary medical centres across the country, has resulted in medical officers (MOs) taking on double roles of HOs and MOs.
The combination of exceptionally long work hours, extended periods in contract positions, mismatched salaries, increased clerical and clinical workloads, perceived lack of transparency in career advancement, and bureaucratic inertia has led to widespread frustration, demoralising and demotivating HOs, MOs and even specialists throughout the system.
There have also been allegations of mistreatment, bullying, abuse, workplace exploitation and accusations of a general toxic work culture. This has contributed to the reasons behind mass resignations, further stressing and worsening conditions for those remaining and continuing the cycle with no real remedy in sight.
Our healthcare professionals, which also include pharmacists, medical assistants, dentists, are not getting the support they need for them to build careers, be safe in their workplace, or be given a reason to stay.
The numbers reported by the Health Ministry to Parliament during replies
to parliamentary questions describe stories of pain and suffering, and a silent cry for help.
Housemen appointments fell by almost 50% from 6,136 in 2019 to 3,271 in 2023. Between 2021 and 2023, 3,046 contract MOs resigned, which saw a peak of 1,354 resignations in 2022.
Seven-year data from 2017 to 2023 showed a rising trend of resignations among contract doctors. The Covid-19 years saw a drastic uptick in that trend.
Every other week, hospital departments are holding farewell parties for doctors leaving their service.
In a case of too little, too late, despite permanent positions being offered to contract doctors over the past two years, the unyielding and uncompromising conditions imposed by permanency, particularly mandatory relocation, resulted in the loss of healthcare personnel as opposed to retaining them.
In 2023, 20% or 1,118 of the 5,489 MOs offered permanent posts did not report for duty, deciding to walk away rather than be displaced.
The number of specialist doctors the Health Ministry employs has also suffered. Resignations among this scarce cohort rose by 57% from 229 in 2019 to 359 individuals resigning in 2023. The latter was the highest in the past five years.
Almost every specialty area was affected, from paediatrics and internal medicine (the two had the highest number of resignations for 2022 to 2023) to urological surgery and transfusion medicine (the lowest).
Malaysia is 2.5 times poorer in terms of nursing staff strength compared to its neighbours. The OECD (Organisation for Economic Cooperation and Development) average for nurse-to-population ratio stands at 9.2 per 1,000 population. Malaysia is currently at 3.6 per 1,000 population.
There is also a trend of mass resignations of nurses from the public health service.
The number of vacancies for nurses steadily increased over the past five years, from 2,106 in 2020, to 2,224 in 2021 and 4,420 in 2022. In 2023, there were 6,896 vacancies which remained largely unfilled.
In some major hospitals, entire departments are reportedly losing the bulk of their nursing teams as they submit their resignations together, leaving for the private sector or other countries such as Singapore, Dubai or Brunei for higher pay, work-life balance and better working conditions.
Resignations of Health Ministry nurses with post-basic qualifications have doubled over the past five years, to a high of 118 in 2023. These chronic staffing shortages even resulted in the ministry directing that specialist
nurses be relocated, creating a wave
of resentment, disruption and dissatisfaction. Nurses do not complain as loudly as doctors. They just speak with their feet. By then, it would be too late.
According to a survey on nurses’ salaries in Asean countries, Malaysian nurses’ monthly wages are among the lowest in the region. A nurse could have more than a decade of experience but the basic salary would remain stagnant at RM2,600, and with allowances possibly reach RM3,800.
Other countries are looking to Malaysia as a source to recruit competent, skilled and high-quality nurses to ease their staffing shortage. They are actively sending recruitment teams for interview sessions at hotels where walk-ins are welcome, and sign-on bonuses are being offered.
In some areas, the rate of resignations has been estimated to be nearly three times higher than the rate of expansion of the public healthcare workforce.
In recruiting and retaining healthcare workers in the public healthcare space, the battle is being lost because there appear to be different rules and realities being applied in the area of human resource management of the public healthcare system.
The public remains largely unaware of the situation, reassured by politicians’ repeated claims that Malaysian healthcare is and will remain among the best and most affordable in the world. These portrayals often overlook the realities of economic pressures, healthcare inflation, the true cost of care, pandemics and the challenge of maintaining a world-class healthcare workforce.
Urgent and meaningful solutions, along with institutional reforms, are needed in this area. Business as usual is no longer an option.
While raising pay scales and on-call rates is helpful, addressing work conditions and workplace culture is mission critical.
Firstly, there is no single solution that can immediately solve all the issues mentioned earlier. However, the government can start by publicly committing to removing and separating the employment, welfare and general management of healthcare professionals under its care from the Public Service Department (PSD) and to establish a Health Services Commission.
The commission would be responsible for appointments, confirmations, placements, promotions, transfers and disciplinary actions.
This is not unprecedented; it mirrors the Education Ministry’s model, which established the Education Services Commission through legislation in 1974 to manage these matters for teachers. Healthcare personnel require similar management by individuals who understand, appreciate and care about the conditions on the ground and the necessary solutions.
This commission should have the authority to oversee the salary scales for the healthcare professionals under their care. Based on its policies, decisions and actions over the past decade, it is clear PSD has encountered challenges and has struggled in its understanding of the depth, complexity and gravity of the problems faced by the healthcare professionals working in the public sector, especially within the context of the country’s health security.
It has been viewed as cold, uncaring, lacking compassion in decisions and disconnected on issues related to positions, staffing, remuneration, working hours and career development. Its decisions have contributed to the widespread dissatisfaction among administrators and leadership of the public health sector.
Secondly, the outputs from the Healthcare Work Culture Improvement Task Force (HWCITF), formed in 2022 under former Health Minister Khairy Jamaluddin, must be reviewed and reassessed.
While the bold step of forming an independent task force to evaluate the Health Ministry’s work culture was commendable, its effectiveness was undermined by the task force members’ reluctance to fully expose the extent of workplace bullying.
Despite benefiting from over 14,000 pages of comments, suggestions and inputs provided by over 110,000 respondents from within the public healthcare system, the HWCITF’s findings and its overall 162-page report were considered sloppy, and it barely analysed the problem that it was formed to look into.
It failed to properly describe or identify the extent of workplace bullying in the ministry’s hospitals, clinics and healthcare facilities.
The findings from HWCITF’s 23-page survey, along with engagement sessions with medical groups such as the Malaysian Medical Association and “Hartal Doktor Kontrak”, hospital directors and key institutional figures, created a valuable and unprecedented resource – comprehensive and rich in detail. This should have served as a key reference for future human resource strategic planning.
Unfortunately, the task force’s final report barely utilised or analysed the 14,000 pages of material.
There are many reasons to join, remain, and grow in the public healthcare sector, whether as a nurse, doctor, medical assistant, pharmacist or even an orderly. It is public service at the highest level, especially for those committed to building their careers in this field.
However, it is crucial to acknowledge that while healthcare workers dedicate themselves to meeting the needs of others, they too must receive the support, care and assistance they deserve.
The practice of romanticising sacrifice, suffering and pain as rites of passage for healthcare professionals needs to stop. This mindset legitimises exploitation, abuse, harassment, bullying, framing them as acceptable within the context of public and national service.
Most importantly, the system must listen to and take seriously the concerns and views of our healthcare workers, treating them with respect.
We need a transformation of our healthcare system to attract and retain top talent and to foster a fair, equitable and just work culture.
The writer is the CEO of the Galen Centre for Health and Social Policy. Comments: letters@thesundaily.com
