KUALA LUMPUR, Feb 14 — A pharmacist working in the Ministry of Health (MOH) central administration has highlighted the lack of mental health protection for government health care professionals and workers.
The pharmacy officer claimed that when complaints are lodged about abusive superiors and staff welfare, top management brushes off these complaints by highlighting that salaries and the ability to resign whenever they wish are the only rights that civil servants have.
Superiors also allegedly push policies to meet key performance indicators (KPIs) to highlight their own departments, rather than tailor them to meet the needs of the department.
In addition to the above, the government pharmacist touched on poor management leading to unequal resource distribution, system inefficiencies leading to a lack of patient care, and a lack of action when it comes to reforms.
The MOH pharmacist was among the 1,652 respondents of CodeBlue’s poll among government health care workers last month that revealed 95 per cent believe Malaysia’s public health care system is currently in crisis, 98 per cent are angry at the situation, 73 per cent are thinking of quitting their job, and 52 per cent are willing to go on strike if one is organised.
On workplace issues, 83 per cent perceive that the government isn’t serious in addressing issues in the public health care system, 80 per cent say they’re underpaid, 78 per cent complain of overwork, 74 per cent suffer from burnout, and 61 per cent feel insecure about their career progression. A quarter allege workplace bullying, while 2 per cent claim workplace sexual harassment.
Below is the pharmacist’s story in their own words. As civil servants are prohibited from speaking publicly, CodeBlue is providing them anonymity. The transcript of CodeBlue’s interview with the pharmacy officer has been lightly edited for clarity.
We Are Health Care Workers, But We Don’t Acknowledge Mental Health
There is inequity in service delivery. Doctors want to deliver service, but the mental health of health care workers is not being prioritised. This was my experience when I was working in the hospital – I developed depression. The working environment was so toxic, but I had to just learn to manage this environment.
Your colleagues tend to judge you the moment you step into the psychiatric clinic.
In my case, I’m a pharmacist. I went to see my superior and I said, “This workplace is a gateway to hell. I’m not able to tolerate it and I have started to have insomnia; it really affects my quality of sleep. I have panic attacks and all those issues.”
She replied, “Oh, no. Why don’t you go and see a counsellor first? We try to keep things under the table because the moment you have a history of psychiatric visits and everything, it won’t look good on you.”
Pharmacy officer, MOH central administration
The stigma is there because the moment they see that you are a psychiatric patient, you are seen as no longer a productive person.
Actually, there is no such thing. You can be a productive person, but because we are trying to seek help, that is how they see it.
So it means that I should not seek help for myself and I should still be productive because you want it that way. So my health is being compromised. This happened to me and a few of my colleagues.
They are my seniors, who actually went through hard times as well. They started going for psychiatric treatment, but people placed a stigma on that.
The colleagues, who think they are normal, say, “You don’t know how to manage your stress, is it?’ So, they look down on you because they think you don’t know how to manage your stress, but they don’t understand that everyone has different coping mechanisms.
The point is that we are all health care workers, but we don’t actually acknowledge mental health as one of the components of health.
Pharmacy officer, MOH central administration
Even my colleague, who was an HIV patient – people saw him differently when knowledge about him being an HIV patient was spread in the hospital and facility. The way they see him is different.
The stigma exists, especially for mental health, but they don’t want to address it.
The triggering point is when we spend most of our time in the hospital. That is our workplace. We spend almost like eight to nine hours there. And sometimes when we are on-call, we almost spend like half a day in the hospital. That actually carries a lot of impact on our mental health.
But our superiors don’t want to tackle that. I’m spending more time in the hospital, and that setting is triggering me, giving me a lot of anxiety issues and insomnia, but you don’t want to address that?
I really have truly given up. I have to admit, I have given up. I don’t think that we can actually make progress…I’m not sure…Miracles happen.
It’s really overwhelming. I have a doctor that will actually scream at all his patients, at all his colleagues. He will scream at everyone. But I kind of understand him now, because the moment he screams, people don’t approach him. People don’t kacau him. So he kind of makes himself free a bit.
It happens. This all happens.
The Only Privilege A Government Servant Has Is Your Salary And Ability To Quit
There are a few factors leading to the health care crisis. Based on the current issues, it’s the lack of human resources. On statistics, for example, the main professionals, like the ratio of doctors, we have already achieved the World Health Organization (WHO) standard, but the ratio is not relevant because the ratio preset by the WHO is basically across different economic status of countries and health care systems — so you can’t apply it directly to us.
We also have to analyse the distribution of these doctors across the country; this applies to all other health care professionals as well.
Another reason for the health care crisis is the inefficiency of managing the resource, which includes finance.
What I have experienced in the past 15 years or so is that we tend to spend money for the wrong reasons.
Pharmacy officer, MOH central administration.
Let’s say in headquarters, there’s a lot of money and there’s a lot of resources. They tend to spend the money on acquiring one printer for one officer, so each officer will have their own printer, but at the hospital level, staff have to recycle A4 papers.
Do you see the extreme point of this? So this is what actually happens.
I have worked at the facility level where we have to keep track of our A4 paper usage, but on the other hand, there are headquarters full of printers and papers and each officer has one printer. That is at the Putrajaya level. That is the inefficiency of resources.
The third reason is the lack of incentive for health workers to perform. Basically, staff are conditioned in the very old tradition of yang menurut perintah.
Pharmacy officer, MOH central administration
So when that happens, even if you have ideas and things that you can bring to the table that actually can help things to deliver better service, but because the bosses aren’t keen on it, or they don’t have an opinion on it and they only have their opinion, you have to follow what they say.
There is no opportunity given by superiors to their subordinates to perform. And not only that, they also provide negative criticism. So once you get negative criticism, this demotivates subordinates and then they will say, “Okay, fine. I just follow orders.”
For years, it has been like that. How do you want to change that? It requires a lot of unlearning of the process.
That is why I don’t believe that we can actually solve this problem because it is deeply rooted in the system.
Every year, there will be a kajian kepuasan, which means that all staff can give their feedback on the organisation. Recently, there were a lot of negative comments against superiors: they tend to scream and bully.
Following that, as a plan of action, there was a discussion with subordinates, in which one of the officers said, ‘Hak sebagai penjawat awam adalah gaji dan anda boleh letak jawatan.’ (The only privilege a government servant has is your salary and you can choose to quit.) So, basically trying to say, ‘Deal with it.’
The context was that she was talking about annual leaves and every aspect of serving as a government officer. Of course, there is a need for certain give-and-take. There is a need for extra flexibility in all organisations, but the flexibility here depends on hierarchy.
The bosses don’t see the bigger picture; decisions are driven by ego.
What I’m saying is what I perceive through my experiences serving here.
System Inefficiencies Cause Staff To Lose Their Human Touch
On another level, the infrastructure.
For example, I have worked in a hospital in an outpatient setting with congested infrastructure. That hospital is one of the state hospitals that caters to almost a thousand patients in the outpatient pharmacy, but we only have four to four and a half counters to cater to this amount of patients.
This is from 8am to 5pm. It means that one counter has to dispense 200 to 300 prescriptions, and the space is very small actually. You can go to one of these hospitals and view how these counters work.
I have worked in outpatient settings.
So you can imagine, 8am to 5pm, I’ll get exhausted. The only thing I can do is dispense. I can’t even talk to the patient or really have conversations. There are times, I admit, when I won’t even smile at the patients because I just want to clear the counter. There are a lot of cases waiting.
Pharmacy officer, MOH central administration
Imagine this on a larger scale. How can we change this?
It requires a lot of planning and delivery. This requires a system change. It goes both ways: top to bottom, bottom to top.
Apart from that, there is no integrated system between facilities. Each facility has its own system. For example, at the pharmacy level, we have this system called the pharmacy information system. This pharmacy information system is not integrated with the hospital system. It actually exists by itself. So every time a patient comes in, I need to key in or transcribe the prescription into the system.
Can you imagine the delay that causes? That is actually one of the reasons why patients have to wait.
If you’re really a fast expert, it’ll probably take about five minutes. It depends. If it’s an old staff, then it might take longer, but you have to put one designated person just to key data into the system. But they’re not adding any additional staff to do the data entry.
They want to introduce a system, but they don’t have any additional human resources to deliver the system or to manage the system, so I use my pre-existing pharmacy assistant or pharmacist to key in data into the system. But now, I’m losing staff at the counter.
Pharmacy officer, MOH central administration
So, this is what happens: most of the time, the data entry can’t happen during peak hours, especially 9am to 12pm or 1pm. What pharmacists tend to do is to key data into the system later. It is not real-time data entry because the pharmacist, the person on the ground, knows they can’t handle it.
Superiors are obsessed with the countersign. Countersign refers to the act that the prescription containing medications under the prescribing category of specialist/ consultant must be countersigned by a specialist or consultant.
This is my personal opinion: if I already know the prescription is coming from the respiratory clinic, I already know that this patient has been seeing specialists, and we all know, we can see the diagnosis, and we kind of know already what medication. We, pharmacists, know also the clinical practice. We know that this medication has been consulted with the consultant and everything.
So, you don’t have to ask each patient to walk all the way back to the clinic to get the signatures and everything.
This is what I mean when I say there is no integrated system between facilities. Therefore, if the patient goes from hospital A to hospital B and he doesn’t carry his history, the hospital B doctors have to go back to review the history and everything is delayed because of that.
Pharmacy officer, MOH central administration
In my career, I have come across many health care workers willing to serve, but it’s beyond their capacity.
The issue in Kelantan that recently went viral – about a teenage patient being denied admission to Pasir Mas Hospital – I actually understand both sides.
I understand the mother: I want the doctor to see my son and he should be kept in the ward. But there is no capacity in the ward, so the doctors, at the end of the day, tend to be rude. It’s not by choice that they want to be rude; there is just no other way.
I’m not justifying that what he did was right, but that is what is happening and that is what is real.
So as I said, even at the outpatient pharmacy, when I’m a dispenser, most of the time, I won’t be smiling because most of the time I’ll just want to deliver the service because the patient is waiting for so long.
I just want to get things done and so that I can entertain the next and the next and the next. And that’s how it works.
In the hospital setting, patients become numbers. They are no longer humans. That is the real way of doing it, and that is the very reason also for me to want to go private.
Pharmacy officer, MOH central administration
Whenever I need acute care, even for my parents, I immediately bring them to a private hospital. I can’t delay the treatment process, which will be delayed in the government sector. I know how things work. So I just go and get things done in private.
Since I have a little medical background, I understand what they are saying, so I don’t allow myself to be cheated as well.
In the private sector, they tend to charge more and everything. So you just have to make sure your negotiation or your discussion is very clear. I have some medical literacy knowledge and I can bring it, but how about the public?
Bosses Design Policies Based On Personal KPI, Not The Needs Of The System
The main reason our health care system is going to collapse sooner or later is because our primary care is failing. You can simply argue based on the data given that we are actually spending more on tertiary care, but we are not spending much on primary care.
When it comes to health, you have got the social determinants of health. To what level is our health, how health promotions work, and other social determinant factors like our neighbourhoods, our academic status, and our education influence health status. All these are a very critical component and are delivered to each individual and to the society as overall.
But are we designing policies that encompass all these components? I don’t think so because I know how management is designing policies. It’s what they want.
It’s very simple. Management is designing policies based on this one thought: “This is my KPI; I must make sure my KPI is achieved.”
So, bosses don’t deliver policy that actually takes into consideration other sectors that could be affected by the policy.
That is how the policy is being designed.
I think our health care system is just right on the edge. There are a lot of good people in the sector – all the health service workers are somehow trying to deliver their service. But beyond that, we will collapse sooner or later.
Pharmacy officer, MOH central administration
The system is all about survival mode.
It means that if a patient develops a stroke, the institution would only function to keep him alive. What kind of quality of life he would have, we don’t know. Whether we could prevent stroke for the next generation, I don’t think so because we will be spending more time on treating the stroke of the current patient.
That is how it works.
It’s all about managing or trying to keep people alive, rather than people having a good quality of life.
That is the reason why I think the public health care system is failing. I’m not convinced we can revive it because it requires a lot of changes, top to bottom, bottom to top.
There is no proper engagement with stakeholders. This is very classic. I think if you interview a pharmacist, they would actually say, “Pharmacists are shiok sendiri.”
Shiok sendiri means they like policies that make the light shine on the pharmacy department.
But you (the pharmacy department) are actually an integrated part of the health, so whenever you want to come up and deliver service, you’re supposed to bring in all other people into the policy, but it does not happen that way.
MTAC (medication therapy adherence clinic) is where pharmacists are a part of the clinic setting. Outpatient clinics where patients will also see a pharmacist, it’s very good idea because the pharmacist will sit hand in hand together with the doctor, or the patient will also see the pharmacist, so the pharmacist will keep a review for doctors to pay attention to, and after seeing the doctor, the patient will come back to the pharmacist as well.
They want to expand this service across all the departments without proper training, without enough staff, just because there is one particular hospital that has the highest number of MTAC clinics in Malaysia. But they can’t deliver because they don’t have enough people.
Pharmacy officer, MOH central administration
So, that is why I say it is shiok sendiri. You don’t have to have 20 MTAC clinics just to say, “Oh my hospital has 20” when they bentang at the national level. They like to proudly say, “I have 20 MTAC clinics in my facility”, but at the ground level, what kind of quality are you producing?
We have existing staff, but there is no additional specific person that is charged with MTAC. I have to come out of the outpatient department just to go to the MTAC clinic from morning till noon, and then I have to go back to my outpatient department. And now, you imagine there’s 20 clinics running concurrently. How many pharmacists will go out?
So, this is what happens just because someone says, “We have to expand our service”. These are very classic pharmacy problems. “Kita kena kembangkan perkhidmatan.”
You are supposed to optimise whatever system you are delivering or whatever service you are delivering. They don’t do that.
For example, this hospital that I worked at is a place where most of the patients will come to collect medication. They only want the SPUB, sistem pembekalan ubat bersepadu– it is a system which allows you to collect medication from another facility.
Another service is a postal delivery service. The superior at the JKN (state health department) level will insist, “You add one more SMS text ambil”. But people actually don’t engage in that. But they will still say, “No, no, no. You must add on. You must add to that”.
So, we just add on, but there is no service delivery for the SMS. It’s very difficult. Most of the time, we’ll have a lot of complaints because either bertukar ubat or something else happens.
They don’t understand in terms of optimising the service. They say “expand”, we expand. There’s no sort of impact analysis being done, but you just add on another service. So this is one of the problems I’ve seen.
Policies Should Adapt To Different Cultures, Like Sabah And Sarawak
In East Malaysia, they’re even more pathetic. Sabah and Sarawak are truly pathetic. They don’t even have proper infrastructure, like a sufficient number of clean rooms or state warehouses, especially in Sabah. A clean room is used for total parenteral nutrition and for cytotoxic drug reconstitution.
They have always been struggling with this because they don’t have proper facilities. They don’t have the proper infrastructure to deliver this service.
Pharmacy, whenever they develop policy, they never take into consideration Sabah and Sarawak in terms of service delivery, and whether this policy can actually be adapted to the Sabah and Sarawak culture. It’s two different worlds, and you can’t design one shoe for everyone.
Pharmacy officer, MOH central administration
Every time, they will push the same thing.
In East Malaysia, for example Sabah, patients like to come to the district hospital because that’s where they meet their friends because all of them are coming from far. And this one particular day, they’ll have this tamu like a pasar mingguan. So, they’ll come on that particular day, and on that day, it’ll be congested.
The superiors say, “You must redistribute your patients to some other days. Give a different appointment day, do the SMS”. But it doesn’t help. These are interior people; they may not carry a smartphone.
So, it requires a different way, a creative way that actually takes into consideration the culture of that particular facility.
These people from the peninsula, the bosses, they will say, “No, no, no, no. You have to deliver this. Kenapa you tak buat yang ini? Kenapa you tak buat yang itu?”.
If I do it, it’s not going to be delivered in an optimal way because it’s not the culture that is working here. If you go to Klinik Kinabatangan or Hospital Semporna, it’s different. It’s a totally different world.
So you can’t justify your KPI at the national level to be implemented at the state level. Of course, the basic one you can achieve, but you can’t simply ask them to expand the service.
One of the major drawbacks that pharmacy is contributing towards the collapse of the health care system is they are shiok sendiri and the way that they design policies is not actually tailored according to the need of the facilities or whatever.
They don’t see a different picture or different side of the coin whenever they define the policy.
Constant Research And Inaction Are The Root Of Reform Failures
The system requires a lot of change.
Start with a simple thing: Can we add more human resources? It’s not that easy actually. The JPA (Public Service Department) is another god that we have to make peace with.
It requires an annual remuneration for these tasks and how much money we have. Despite having a lot of money, how much money are we going to allocate to the annual remuneration of these tasks?
I just do whatever work that you want me to do. I’m not really working on my passion. If management is not letting me go, I might want to quit, but I’m worried about whether I can get the same salary as I have commitments.
I can quit my job anytime I want, but the only reason that I’m still contemplating is whether I can survive in other sectors and other issues that I need to think about.
But other than that, I’d just rather leave the government because there’s no point. I don’t see any good things that are going to come sooner or later.
Pharmacy officer, MOH central administration
So what can they do? I think to start with, of course, the human resource is the main thing, but apart from that, they really have to redo how the health care system works, which is not going to happen because we already have done the Malaysia Health System Review. The report is already there. It was published in 2012, but we’re not doing anything about it.
We do more and more research. We already know that whatever research we are going to do, we are going to come up with the same findings. It’s not going to make any difference because there are no policy changes.
Pharmacy officer, MOH central administration
Policy changes require a lot of integration between the health care systems: both public and private, but that’s not going to happen.
That’s why I gave up. I don’t think anything good will come from my interview with you, but I appreciate the efforts nonetheless. This is what we call a hopeless, helpless state. That is what we are.
I actually was trying to look at migrating. The only reason I haven’t migrated is because of my family; otherwise, I would have migrated.
Changes require health care reform, but I’m not sure how far this will go because political willingness is required for that.
If they are able to bring in health reform and they execute it sooner or later…I mean, how fast they can do it might change my perspective, but being a government servant for more than a decade, I doubt it can be done in a short period of time.
So, for health care reform, it is not going to be very easy, but I think if they’re able to tabulate the health care reform, and see whether they’re able to increase the human resource for the next five years.
That includes how they’re going to certify the doctors, how they’re going to bring in the medical students, how are they going to add more staff in the system and in the organisations and make sure they are evenly distributed. While HKL (Hospital Kuala Lumpur) has a lot of people, somewhere in Hospital Semporna, they’ll be struggling with only one or two doctors.
I think this is the main thing that is actually affecting delivery of service.
Apart from that, we also have to see in terms of adding infrastructure, but adding infrastructure should not be like Hospital Cyberjaya that is pulling existing human resources from other facilities. They’re not actually creating new posts for the new hospital.
So if you open a new hospital, but you try to pull existing officers from elsewhere, how do you think those existing facilities will run? You’re not bringing in new staff into the system.
Pharmacy officer, MOH central administration
If they are able to do it, I might be convinced. But yeah, as I said before, I have kind of given up, so my opinion can be biassed because of my very strongly conditioned mind.
Let’s see how the government and the system work. You need to understand that it’s not only the government, it’s actually other government offices deciding this.
For example, a pharmacy requires another 600 pharmacists, but the deciding person is actually another government official in the JPA. So you have to see what their policy is and what their vision is. What is their KPI, and what is the ego that drives their horses?
That is actually the implementation here. So it’s not only the government per se, it’s actually fellow government staff who are also ruining the system.
So how do you want to change that?
That requires a lot of unconditioning, a lot of unlearning of the previous way of doing work because we are a colonised country, and we tend to adopt British culture.
Whatever the NHS is facing is basically the same thing that we are facing because we actually adopted the same way of working.
It may not be the optimal way to strengthen our own health care system by adopting another country’s system or another philosophy into our country because after Independence, we don’t have anything particularly similar to them.
Over the years, there should be a way forward as to how we can actually tailor the system according to our country’s culture.
For example, our food is different, and our food is contributing to the main NCD (non-communicable disease) crisis. It’s as simple as that. If you go to a simple R&R, you will see more meat than vegetables.
But then on the other side, you are arguing, “Oh, Malaysians should eat more vegetables. Malaysians should take more fibre”.
You’re not even able to provide that. So how do you want to change all of this on a national scale so that we are able to change the overall health delivery in our country?
It requires a lot of effort.
