Transforming our healthcare workforce

 

From Azrul Mohd Khalib

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 increasingly chronic human resource shortage has created a vicious cycle amid a backdrop of large numbers of people accessing public hospitals’ emergency and trauma departments, and outpatient services, and congestion in the waiting rooms at government health clinics (Klinik Kesihatan) nationwide.

The availability of house officers (HOs) or doctors-in-training has decreased significantly over the past few years, despite increasing need, multiple intakes and the annual availability of fresh medical graduates.

This shortage affecting most district and tertiary medical centres across the country has resulted in medical officers (MO) taking on double roles of both HO and MO.

Combined with their exceptionally long work hours, prolonged time in contract positions, mismatched salaries, increased clerical and clinical workloads, perceived lack of transparency in pursuing career opportunities, and bureaucratic inertia and disinterest, the situation has created massive frustration, demoralised and demotivated both HOs and MOs, and even specialists across 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.

Simply said, our healthcare professionals – including pharmacists, medical assistants and dentists – are not getting the support they need to build careers, be safe in their workplace, or even to be provided with a reason to stay.

How bad is it? The numbers reported by the health ministry to the Dewan Rakyat 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 medical officers resigned, with 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 having 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 instead in the loss of healthcare personnel as opposed to retaining them.

In 2023, 20% or 1,118 of the 5,489 medical officers offered permanent posts did not report for duty at their placements, 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 specialists in 2023.

The latter statistic is 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 (lowest).

Mass resignation of nurses

Malaysia is 2.5 times poorer in terms of nursing staff strength compared with its neighbours. The OECD 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 an ongoing trend of mass resignation 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.

The number of nurses with post-basic qualifications leaving the government service has doubled over the past five years, to a high of 118 in 2023. These chronic staffing shortages even resulted in the health ministry ordering specialist nurses to be relocated to wards, creating a wave of resentment, disruption and dissatisfaction.

Nurses don’t 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 her 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 own 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.

Different rules and realities being applied

In recruiting and retaining healthcare workers in the public healthcare space, the battle is being lost simply because there appears to be different rules and realities being applied in the area of human resource management of the public healthcare system.

The public is mostly blissfully unaware of what is happening, comforted by the often repeated portrayal by politicians that Malaysian healthcare is and will always be among the best and cheapest in the world, that we are untouched by the realities of economic pressures, healthcare inflation, the real cost of healthcare, pandemics, and the challenge of keeping up a world-class healthcare professional workforce.

So what can be done? Meaningful solutions and institutional reforms in this area are urgently needed. It cannot be business as usual.

Tokenism and half-measures will be seen and recognised for what they are. Raising pay scales and on-call rates are good but addressing work conditions and work culture are mission critical.

Firstly, there is no single solution that can immediately solve all of 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 services department (JPA) and to establish a Health Services Commission.

The commission would be responsible for matters relating to appointment, confirmation, placement, promotion, transfer and disciplinary measures.

This is not an extraordinary measure. It follows the example of the education ministry which has the Education Services Commission, established through legislation since 1974, to do for teachers what healthcare personnel need done for them.

Healthcare personnel must be managed by people who appreciate, understand, know and care about the conditions on the ground and the remedies needed.

This commission should have the authority to oversee the salary scales for the healthcare professionals under their care.

The fact is that based on its policies, decisions and actions over the past decade, it is clear JPA has encountered challenges and have struggled in their 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 even administrators and leadership of the public health sector.

Revisit report on bullying in the workplace

Secondly, the outputs from the Healthcare Work Culture Improvement Task Force (HWCITF) formed in 2022 under the previous health minister, Khairy Jamaluddin, need to be reviewed and reexamined.

The bold move of setting up an independent task force to review the health ministry’s work culture was completely undermined by the taskforce members’ timidity in revealing the extent of the problem of bullying in the workplace.

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 barely analysed the problem that it was formed to look into, namely bullying.

It failed to even properly describe or identify the extent of workplace bullying in government hospitals, clinics and healthcare facilities.

The results from HWCITF’s 23-page survey, together with engagement sessions with medical groups such as the Malaysian Medical Association (MMA), and Hartal Doktor Kontrak, hospital directors and key figures in the institution, contributed to the formation of a valuable resource unprecedented in depth and richness of detail which should have been a guiding reference for future human resource strategic planning.

Too bad that the final report from the task force was not fully used and that it barely analysed the 14,000 pages of comments. Don’t reinvent the wheel, just analyse those outputs which hopefully have not already been destroyed or deleted.

There are many reasons to join, stay and grow in the public healthcare sector whether a person is a nurse, doctor, medical assistant, pharmacist or even an orderly.

It is public service of the highest order, especially if you have made a commitment to developing your career there.

However, it is vital to recognise that while this field involves meeting the care and needs of others, it is necessary that healthcare workers themselves be given the support, care and assistance that they need.

The practice of romanticising sacrifice, suffering and pain as being part of the rite of passage for healthcare professionals needs to stop as it enables for exploitation, abuse, harassment, bullying to be clothed in legitimacy, public and national service, and accepted practice.

Most importantly, the system must listen to the concerns and views expressed by our healthcare workers and treat them with seriousness and respect.

What we need to ensure and transform our healthcare workforce to attract and retain top talent in the public healthcare system is to develop and build a fair, equitable and just culture. - FMT

Azrul Mohd Khalib is the founder and CEO of the Galen Centre for Health and Social Policy.

The views expressed are those of the writer and do not necessarily reflect those of MMKtT.