INTERVIEW | The contract doctor system was introduced in 2016 during the BN administration under Najib Abdul Razak.
Five years on, what was intended as a stop-gap has developed into one of the biggest controversies in the healthcare system.
Dr S Subramaniam was the health minister from 2013 to 2018 and oversaw the implementation of the system.
In a recent interview with Malaysiakini, he explained the initial reasons behind the move.
With Perikatan Nasional’s collapse, Subramaniam also offered new Health Minister Khairy Jamaluddin some ideas on how to solve the conundrum, once and for all.
Cause: Implementation weaknesses
The contract medical officer (MO) system was introduced at a time when the number of medical students waiting for training placements in the health ministry was at a high, Subramaniam recalled.
This stemmed from a planning problem stretching back to the 1990s. At the time, new medical schools were being approved without taking into account how students were going to be trained.
As a result, the 33 institutions nationwide - 11 public and 22 private - began turning out more graduates than the public healthcare system had MO posts for.
By 2016, there was a serious backlog. As the minister, Subramaniam said he had needed a quick fix that circumvented the thorough Public Service Department (PSD) employment process.
“There was a huge backlog, and it was building. So, the only way the health Ministry could actually solve this was to find some way to create more posts.
“Contract posts could be created on-demand, without the need to go through that (PSD) process.
“So, these contract posts were created to make sure this huge number of doctors who were coming into the system would be able to undergo mandatory training,” he recalled.
While this contract MO system had been a “necessity” at the time, it was meant to be a salve until a proper solution could be implemented.
“Essentially, it was not meant to be a permanent system,” Subramaniam said.
So how did this temporary solution morph into a problem of its own?
Subramaniam pinned it on “implementation weaknesses”.
He claimed that wage disparity, ineligibility for local postgraduate training programmes and an opaque hiring process were not the intention of the system’s architects. Neither were these features in the original plan, he stressed.
“That kind of discrimination was never (in the plan). Even though we introduced the system, when the policies came to be implemented, they subsequently took a different direction.
“Over the period of the implementation, somehow or rather some weaknesses came,” he said.
Disease: A two-tier system
In its Dec 15, 2016, circular announcing the contract system, the ministry had said that contract MOs, dentists and pharmacists were to receive “equal emoluments” as permanent officers.
Permanent posts were to be offered in a “backdated” manner to the “best talent” who completed their training and fulfilled all criteria, provided such posts were available.
The circular did not mention if contract officers were eligible for local postgraduate studies but noted that the backdated permanent hiring system was to ensure the “best talent or officers with the potential to pursue specialist studies” were hired.
However, in practice, contract MOs were initially paid less than their permanent counterparts. This gap was narrowed in November 2020.
They are also ineligible for local postgraduate scholarships to become specialists.
Furthermore, they are not guaranteed permanent posts after their five-year contract. This was on top of a lack of transparent criteria for deciding which graduates obtained a permanent or contract post in the first place.
As more contract MOs suffered burnout after being sent to the Covid-19 frontlines, these young doctors staged walkouts last month demanding an end to this two-tier system.
They had deemed PN’s 11th-hour concessions as insufficient, which included a four-year contract extension, better employment benefits and postgraduate study scholarships.
Contract MO groups reiterated that they wanted permanent positions and equal opportunity to further their studies.
The ministry recently offered 300 of the 23,000 or so contract MOs permanent posts but said a third had turned them down. In response, groups said some were given just 48 hours to decide on whether to relocate to Sabah or Sarawak for the job.
Prescription: Fix inequality, supply
There are high hopes that Khairy will finally fix the system.
During the interview, Subramaniam said he had once tried to nip the problem at the bud by solving the oversupply of medical graduates. However, his efforts were thwarted.
As health minister, he said, he had proposed that the SPM bar for entry into medical schools be raised from 5Bs to 5As.
“Our bar for entry into medicine was still 5Bs and this was something that had been there for 20 to 30 years. But things were different now because 30,000 to 40,000 people were scoring 5As in their SPM.
“All we needed was 3,000 people to go into medical school. We had an ample amount of people to choose from. Why don’t we increase the bar to 5As?” he recalled proposing.
Following “heated arguments”, Subramaniam claimed that the Higher Education Ministry had turned down the idea and preferred to maintain the present 5Bs entry requirement.
Asked if racial quotas were the reason for the status quo, he declined to comment.
“They just did not want to allow for that (change). So we landed up with this.
“So all those who can't go into a public medical school are able to get into a private medical school. And in private medical education, (you get in) so long as you meet the minimum 5Bs.
“Beyond that, it is dependent on who can pay and who cannot pay,” he answered.
With the current situation, Subramaniam proposed a two-pronged solution.
The first was to fix the contract system to ensure it was fair. This included giving contract MOs equal opportunity to pursue specialist studies locally.
“It can be solved by extending their contracts for a sufficient period of time by which doctors can commit themself to some specialisation which is possible within the system itself,” he said.
The former minister also proposed that the government increases the number of permanent MO positions available and implements a transparent hiring process.
The next part was to fix the supply-demand mismatch.
There is currently a moratorium on the number of medical schools, the number of medical courses they can offer and the number of students they can take.
Subramaniam, a trained dermatologist, pushed for solutions that were more than skin-deep.
In the long term, he reiterated that the bar of entry should be raised. The government should also set a definitive number of graduates needed by the system and accommodate them for training.
“We can relook at the number of places that are given to universities for undergraduates. We can reconcile the number of places according to the number of seats which we have for training. So, if we do that, I think we can fix the supply issue,” he said.
Once supply matches demand, he sees no more need for the contract MO system.
“The contract MO system was meant to solve the supply-demand issue.
“Once you have a demand that is higher or equivalent to supply, automatically the contract doctor system can cease,” Subramaniam said. - Mkini
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