Materia Medica Malaysiana

Seeking cure for doctor shortage

More than 3,600 doctors left for the private sector in the last 10 years, and there are now vacancies for 3,300 general practitioners and 700 specialists. Alarmed, the Health Ministry may now make it compulsory for private sector doctors to work part-time in government hospitals. But is this the right prescription? YONG TIAM KUI reports

OVER the years, the Government has come up with a number of ad hoc measures to deal with the shortage of doctors in the public health sector. These include hiring foreign doctors on a contractual basis, hiring retired doctors to work in rural areas and allowing government doctors to work part-time in the private sector. Unfortunately, these measures have not worked for the simple reason that they do not address the grouses of frustrated doctors in government service. Their complaints are endless: long working hours, bad working conditions, low pay, lack of opportunities for further education and poor promotion prospects for non-Bumiputeras.. And government doctors are definitely not exaggerating when they say they are overworked. They handle 48 million outpatient cases and 1.7 million in-patient cases a year. The country's 16,000 medical specialists and doctors are about evenly split between the public and private sectors. But, while government doctors have to attend to 32,000 beds, their private counterparts only have 9,000 beds to attend to. They are also paid much less than their private sector counterparts. A government doctor who wrote to the New Straits Times letters page recently says a doctor who has been working in the private sector for 10 years can earn between RM10,000 and RM15,000 a month. A doctor working for the same number of years in the public sector would only be earning RM3,500, a monthly housing allowance of RM160 and a ridiculously low call allowance of RM1.61 per hour on weekdays and RM1.04 on weekends. Obviously, the Health Ministry will have to look at these factors if it wants to retain experienced medical staff. "The root of the problem — why doctors are leaving the public sector — needs to be addressed," says Association of Private Hospitals of Malaysia (APHM) president Datuk Dr Ridzwan Bakar. Health Minister Datuk Dr Chua Soi Lek has acknowledged that there is a need to improve the salary and working conditions of government doctors, and will be holding discussions with the Malaysian Medical Association on this matter. But, it is difficult to see how improvements can be made unless the national health budget is increased or if public hospitals and clinics start charging patients more. As it is, the Health Ministry is carrying out cost-cutting measures which include using cheaper generic drugs and deferring the construction of 11 hospitals which were scheduled to start this year. Dr Chua also challenged doctors and specialists in private hospitals to voluntarily work part-time in government hospitals and universities. "Over the past five years, we have only received seven volunteers. This is the worst form of tokenism ever. I am now throwing a challenge to them: Are they willing to serve on a voluntary basis?" he asked. Dr Chua says the Government may make it compulsory for private sector doctors to work part-time in the public health sector if volunteers were not forthcoming. Under such an arrangement, doctors would be required to work a certain number of hours per week if they want their Annual Practising Certificates (APC) renewed. After all, says Dr Chua, doctors and specialists have to show continuous performance development to renew their APC. "What better place is there to have their continuous professional development than in government hospitals?" The minister's harsh words have angered doctors and the threat to link APC renewals to part-time work in government service has met stiff opposition from the MMA. Its president, Datuk Dr N Arumugam, says doctors should not be forced to work in the public sector because they are already shouldering their social responsibilities as medical practitioners. He notes that medical graduates are already required to work in the government service for three years and many doctors have worked for the government for 10 years or more before leaving for the private sector. "It should be voluntary with appropriate incentives. It should not be linked to the renewal of the Annual Practising Certificate. People who work under compulsion will not do their best work. "I do not know of any examples of a country forcing doctors to work. Like any other citizen in a free society, doctors are entitled to their free time." Dr Arumugam says many doctors and specialists would welcome the opportunity to serve on a part-time basis in the public sector if a proper system was put in place by the ministry. "We can meet the ministry to draw up guidelines. If a system can be worked out, many doctors would be willing to offer their services," he adds. Dr Arumugam's view about the need for guidelines and a systematic approach on the part of the ministry was shared by Dr Ahmad (not his real name), a private sector doctor who lectures at a public university several hours a week. Dr Ahmad, who taught medicine for more than 20 years before leaving for the private sector, says many ex-academicians have not lost their interest in teaching and would be more than happy to offer their services if there was a systematic approach to integrate them into the public university system. "I am sad that the minister has come out with such strong words challenging doctors in the private sector. The minister shouldn't threaten us by linking it with the APC. He should follow Pak Lah's philosophy of come and ‘work with me'. "The onus is on the ministry to work out a systematic programme that links the public and private sectors. The people who need help is the ministry not us." "What kind of recognition and privileges are we going to be given? "Will our former status as professors be recognised or will we be known only as temporary visiting lecturers?" he adds Dr Ahmad says the ministry also should do something about the hostility, jealousy and mistrust that private practitioners face in government service. "The ministry should do a survey of heads of department of government institutions to find out whether they are really willing to take us in. "Once we leave government service, there is a tendency for people who are still in government service, especially those who hold high positions, to have the attitude that they don't need us. There is anger and hostility against us for leaving. That has to change." Dr Wong Jun Shyan who wrote to the NST letters page says he offered his services to a public university but they didn't even bother to reply. He says his case is by no means an isolated one as he has colleagues who have had similar experiences with university authorities. "I left a university-based hospital last year after establishing a tertiary referral unit for complex cases in my area of specialisation. "Realising the scarcity of this speciality here, I offered my time as a visiting lecturer, but I have yet to receive a reply. I know of other instances where my ex-colleagues too offered to do the same," says Dr Wong. Meanwhile, Consumers Association of Penang president S.M. Mohamed Idris suggests that the ministry make better use of foreign doctors to reduce the critical shortage of medical practitioners. He says the current system of contractual employment for foreign doctors should be revamped to encourage them to stay on in the country. One of the measures that can be adopted would be to offer permanent resident status to foreign doctors after they have served in the country continuously for a stipulated period, he adds. This can be scrapped once the country is no longer short of doctors. "After all, the Government is head-hunting foreign experts to serve government-linked companies (GLCs), so why not use the same concept for recruitment of foreign doctors?" says Idris. The shortage of doctors is most severe in rural areas. The doctor patient ratio in Kuala Lumpur is as high as 1:420 but in Sabah it is just 1:2,800. The Government is trying to improve the situation by encouraging retired doctors to serve in rural areas. So far, only 34 retired doctors have accepted re-employment in rural health centres. Dr Arumugam says the ministry should consider requiring medical students who are sponsored by the Government to work in rural areas for one or two years upon graduation. He says the Government can also entice foreign doctors to work in rural areas by offering them permanent resident status after a certain number of years of service. Dr Arumugam says the Sabah and Sarawak State Governments should consider allowing doctors from the peninsula who have worked in the government service in their respective states or a certain number of years to stay on and open private clinics. The Health Ministry is trying to train more doctors so that the country can reach a doctor patient ratio of one to 650. At present, Malaysia has one doctor for every 1,400 people. Dr Chua says about 1,000 new doctors enter government service every year but another 350 doctors resign or retire as well. So, the net increase is only about 650 doctors each year. However, it is difficult for public universities to churn out a higher number of medical graduates because they are desperately short of teaching staff. Like public hospitals, public universities have also been losing large numbers of experienced staff to the private sector. Universiti Kebangsaan Malaysia's medical faculty, for instance, lost 45 medical lecturers in the past three years. APHM is working out a deal with the ministry to allow former university lecturers who are now working in the private sector to lecture part-time in public universities. "They are willing to lecture part-time and this is our commitment to alleviate the shortage of lecturers at public medical schools. "The specialist skills of these doctors are not fully utilised in terms of their specific area of expertise," says Dr Ridzwan.

He says the details will be worked out in a meeting between APHM and the Ministry on June 21. "Malaysia is unique in the sense that the public and private sectors are working rather independently of each other. "This has resulted in duplication of services and inefficient usage of resources. This is why the APHM is promoting private/public partnership."