KUALA LUMPUR, Dec 24 — The issue of contract doctors is paradoxical: on one hand, there are too many applicants fighting over limited permanent positions in government. On the other, not enough doctors are serving the underfunded and overstretched public health care system.
The Ministry of Health (MOH) introduced the contract doctor system in 2016 to reduce the glut of medical graduates waiting for housemanship from over 30 medical schools nationwide.
According to Dr Pagalavan Letchumanan, a consultant physician and rheumatologist at Columbia Asia Hospital Nusajaya, the issue of purportedly excessive doctors started between the year 2000 and 2012 when medical schools started mushrooming.
He said that some medical schools even have two medical programmes, while some have more than one intake of students per year.
“Locally alone, we are producing almost more than 4,000 graduates annually. In addition, we usually have about 1,000 graduates coming back from overseas (this number may have dropped). Since 2017, the Public Service Department (JPA) has stopped overseas sponsorship,” Dr Pagalavan said.
The consultant physician said that the drastic spike in the number of medical graduates was too much for the system to cope, hence the contract system was created to make sure everyone gets to do their housemanship and compulsory service.
Malaysia has a total number of 32 local medical schools (11 public and 21 private) more than Australia, the United Kingdom, and the United States on a per capita basis.
Former Malaysian Medics International (MMI) co-chairman Dr Vikkineshwaran Siva Subramaniam said that the introduction of the contract system was a temporary measure to resolve the backlog issue of medical graduates.
“During that time, some medical graduates had to wait close to two years before they were offered a placement,” Dr Vikkineshwaran said.
However, because the glut of medical graduates was an uncontrollable issue, the contract system, which was initially intended to be a short-term measure, became a permanent “solution”.
In August, Health Minister Dr Adham Baba told the Dewan Rakyat that MOH has managed to increase the total graduate training slots, or in other words, housemanship slots from 10,835 in 2013 to 12,153 as of now.
MOH has also increased the number of graduate training hospitals from 38 in 2009 to 48 in 2019, while a total of six more hospitals are being monitored for the implementation of the housemanship programme.
Furthermore, MOH has also collaborated with a consortium of public university hospitals to increase housemanship slots up to 950 slots to accommodate the placement of house officers.
To further control the number of medical graduates in Malaysia, the government, through the Ministry of Higher Education (MOHE), has extended a moratorium on new medical courses in institutes of higher learning for five years until 2021, covering three aspects — no addition of new medical colleges, no addition to new medical programmes, and no increase in the quota of medical students.
Differences Between A Contract And Permanent Medical Officer
Dr Vikkineshwaran said that all house officers (grade UD41) will become MOs upon completing their housemanship, but MOH or JPA has never released any documents stating that UD41 grade doctors will automatically get an advancement to the UD43 or UD44 civil service grade.
“This was a misconception as back in the older days (that’s before 2016), when doctors were being hired with a permanent position — their career progression was such that after two years of housemanship, they will automatically get a promotion to MO at UD44 level,” the medical practitioner said.
The UD43 grade was only given to a few MOs from the very first batch of contract doctors. However, from the second batch onwards, all the doctors were offered UD41 contract extension to complete their two-year compulsory service.
In November last year, over 9,200 people signed an online petition demanding fair wages and equal opportunity in postgraduate training for contract MOs.
The petition pointed out that contract MOs who were maintained on the UD41 civil service grade were paid a difference of RM664 monthly compared to the higher paid UD44 permanent counterparts, which totalled up to RM 7,968 per year, excluding yearly increments. On the other hand, UD41 grade housemen even get a RM600 flexi allowance which UD41 grade MOs don’t.
Last month, the health minister finally announced that the Cabinet has approved promoting all the UD41 contract MOs to UD43, which means they get the same salary as their permanent counterparts. He did not mention when this will be implemented.
However, this does not guarantee that they will be getting a permanent spot after completion of their compulsory two-year service. It also means that they will still not be able to enjoy certain benefits as what the permanent MOs enjoy.
According to MMI, contract MOs, despite being exposed to similar occupational hazards, same amount of workload, and similar stress levels, those from the Radiology and Psychiatry departments are ineligible to apply for hazard leaves (cuti khas perubatan).
A contract MO is also not entitled to unrecorded leaves (cuti tanpa rekod), even for examination purposes.
Besides that, Dr Pagalavan said that contract MOs are not eligible for the Hadiah Latihan Persekutuan (HLP) to apply for the local master’s program.
HLP is a full scholarship by MOH for doctors to pursue specialisation programmes in public universities while working.
Although doctors may proceed with parallel pathways on their own, they still need a certain number of years of training in either an MOH or a university hospital to become a specialist.
The alternative or parallel pathway is another route for doctors to pursue their specialisation. It is a structured medical specialty training programme by various awarding bodies like Membership of the Royal Colleges of Physicians (MRCP), Membership of the Royal College of Obstetricians and Gynaecologists (MRCOG), Membership of the Royal College of Paediatrics and Child Health (MRCPCH) whereby training and examinations is conducted locally or in combination with overseas centres.
“Passing exams does not make you a specialist. This is where the problem lies again. How are they going to complete training if they have no job!” Dr Pagalavan stressed.
He urged MOH to extend contracts for those who are doing specialisation to be able to complete their training and be gazetted as a specialist.
Malaysia’s health minister, in his written parliamentary reply on July 13, told contract medical officers to finance their own specialisation course and go abroad, as they are not eligible for HLP.
A Fair Assessment For Doctors
Dr Vikkineshwaran pointed out that when the contract system was first implemented, doctors were not guaranteed a permanent position upon completing their housemanship.
In fact, he said, doctors were informed that the good performing doctors will be retained as permanent medical officers (MOs) based on availability of permanent positions and their salary will be backdated accordingly.
The contract states that the a permanent position my only be offered subject to vacancy, if a house officer manages to complete their graduate training programme within the stipulated time, approved by the heads of departments, competent, has good levels of achievements, and has been given a full registration by the Malaysian Medical Council (MMC).
Health director-general Dr Noor Hisham Abdullah said in a Facebook post in 2016 that excellent ones will be absorbed straight as permanent MOs, while the rest will continue as contract MOs and those who fail to be absorbed by the Ministry will have to join the private sector.
Back in August, Bandar Kuching MP Dr Kelvin Yii told the Dewan Rakyat that contract doctors were dissatisfied with the selection process for permanent appointments as they perceive the performance review process as opaque and open to favoritism and biasness.
Dr Pagalavan told CodeBlue that he agrees the current houseman assessment system is not standardised and open to biasness.
He suggested for MOH and MMC to work together to come up with a common standardised assessment system to determine who should get a permanent post along with appointing a common pool of trained assessors.
“Every system has flaws, but we need to try to minimise these flaws,” Dr Pagalavan said.
Each houseman who has to undergo a four-month rotation in six departments will be given a logbook that assesses the houseman’s competency in various clinical and theoretical aspects. The housemen will be supervised and evaluated by MOs, specialists and consultants.
Dr Vikkineshwaran said that although the planning and aspects in the housemanship logbook follows international standards, the implementation and execution of it is subpar.
He recommended for MOH to implement an online logbook for the houseman assessment so that MOH can monitor the house officers to ensure they progress on time, besides identifying and offering help to those who need it.
“MOH can also determine the excellent house officers from this as it would be a more transparent system in grading and evaluating the doctor, and the doctor themselves would be able to keep track of their progress and ranking compared to other house officers at their same level.”
Contract Medical Officers’ Fate After Compulsory Service
Dr Vikkineshwaran said that it is difficult to gauge the fate of contract doctors in the civil service unless they try their luck in other ministries like MOHE or the Ministry of Defence, but ultimately most will end up as general practitioners.
“If a doctor has an intention of improving themselves and moving up the career ladder, they have no other choice but to take up the challenge on themselves to fund and work towards achieving it,” Dr Vikkineshwaran said.
He pointed out that investment in medical training and subsequently specialist training is a personal asset which involves financial sacrifice if a doctor really wants to become a specialist.
“It definitely is unfair, but that’s the reality.”
The Perikatan Nasional government said that contract medical doctors who fail to get permanent positions in the government centres can seek private sector jobs, a familiar refrain expressed by the previous Pakatan Harapan administration.
Health Minister Dr Adham said MOs can apply for jobs in public university hospitals and companies that need workers with knowledge and expertise in health care, like private medical laboratories and pharmaceutical companies.