Many words have been used to describe the state of the health workforce in Malaysia. To pick the most common three, they are: “understaffed”, “overworked”, and “underpaid”.
Health Facts 2022 states that there is just one doctor to 420 Malaysians, or 2.4 doctors per 1,000 population in Malaysia. To benchmark against our neighbours, Singapore has 2.7, Brunei has 1.6, Thailand has 0.9, and Indonesia has 0.6 doctors per 1,000 population.
Singapore has a slightly higher doctor-to-population ratio to Malaysia, but provides one of the best health care services in the world, whereas Thailand, despite having one-third of Malaysia’s doctor-to-population ratio, has one of the most comprehensive universal health coverages in Southeast Asia.
In Malaysia, while workload-staff mismatch is true in the public sector, not all hospitals are affected. Indeed, bad news has a way of convincing us that because something is so bad here (for example, hours of waiting time before being seen by a doctor in the emergency room), it must be true everywhere else.
The 2018 Human Resources for Health Country Profile shows that the doctor-to-population ratio in Malaysia ranges from 1.2 in Sabah to 4.1 in Negeri Sembilan, with a national average of 1.9 doctors per 1,000 population at that time.
Averages can mislead us into believing that there is a lack of doctors when in fact, the distribution of doctors is poorly optimised. To add to what many have proposed, here are three ways to tackle the maldistribution of doctors.
Be Data-Driven In Decision-Making
Whether the health workforce management should be managed by the Public Service Department or the Ministry of Health, decision-making processes must be data-driven.
Traditionally, national staffing needs for health workers are forecasted based on population analysis (as evidenced by the emphasis on doctor-to-population ratio), health service utilisation data such as hospital visits and admissions, and using international benchmarks (the widespread licensing of medical institutions in Malaysia in the 2000s was said to be motivated by the pursuit of the 1:400 doctor-to-population ratio, as “recommended by the World Health Organization (WHO)”), although anecdotes seem to indicate that the production and distribution of doctors were reactive to requests by state health departments in a bottom-up approach.
The Workload Indicators of Staffing Need (WISN) framework developed by the WHO propose a different set of data points. Instead of using patient head counts or service utilisation, activity time is used.
To illustrate, each of the main activities of a doctor is defined and assigned a standard time taken to complete – for example, 15 minutes per patient in an outpatient clinic and 20 minutes per patient in the ward.
The total amount of time is then tallied against the working time of all the doctors in the department, adjusted for some allowances for ad hoc activities like attending meetings and training. The extent of the shortage of doctors’ time against activity time indicates the additional manpower required.
Revise Policy At The Supply Level
Reasonably accurate data will guide the forecasting of the need for health workers. In turn, the supply of medical graduates can be regulated.
Several strategies have been implemented in other countries, such as restricting the number of seats in medical schools, imposing entrance exams, and increasing or decreasing the admission criteria of academic requirements.
There has also been a suggestion to impose personality screening tests to ensure that medical graduates are not only academically qualified, but temperamentally suitable to enter the health workforce.
However, a careful consideration of long-term implications is crucial when implementing measures to limit or increase the number of medical graduates.
More important than the number of medical graduates is where they are from. The maldistribution in the health workforce is partly due to the unwillingness of medical doctors to relocate away from their hometowns.
Therefore, one possible strategy is to create a quota system for medical admissions based on the states they are from. In addition to ensuring equal opportunities to students from rural and urban areas, this makes the best use of the tendency of health workers to serve in their home states after completing their education.
The enforcement of this policy may vary, but it could be a step towards balancing the distribution of health workers across the different regions of Malaysia.
Provide Incentives Via Public-Private Partnerships
Most of the incentives provided for health workers to relocate to underserved areas are financial. For example, medical doctors who relocate from West to East Malaysia are entitled to moving and cargo allowances, and flight and travel allowances for reporting to work.
Notwithstanding scarce financial resources, there is a ceiling to the amount of allowance that the government can give. Indeed, many contract doctors were given non-financial incentives such as permanent posts before they were relocated to other states.
In addition to existing measures, public-private partnerships can be explored. Collaborations with transport companies like Grab or local airlines like AirAsia can offer non-financial incentives for the relocating health workers.
For example, these companies can provide discounted or priority seats for health workers to report to work or to return home for holidays as part of their corporate social responsibility initiatives.
Such initiatives not only make relocation less taxing for the health workers, but also contribute to their overall wellbeing, job satisfaction, and the pride associated with serving the people.
In conclusion, the number of health workers in Malaysia is arguably sufficient when benchmarked against international standards. The root cause for the “understaffed”, “overworked” and “underpaid” experience in selected hospitals is really the maldistribution of health workers.
By utilising data-driven decision making through frameworks like WISN, policymakers can better forecast staffing needs and allocate human resources accordingly. Amending policies at the university level, such as implementing state-based quotas, can help ensure a more balanced distribution of health workers across the country.
Public-private partnerships can provide non-financial incentives to health care professionals, making relocation to underserved areas more attractive.
By being proactive in managing supply instead of being reactive to demand, Malaysia can move closer to achieving an appropriately staffed, worked and paid health workforce.
Dr Ginsky Chan is a public health advocate.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.