Memorandum To The Health Minister And Health Parliament Committee On The Parallel Pathway — 10 Academics And NGO Representatives

Introduction

We express our highest appreciation to the Health Parliament Special Select Committee (PSSC) for organising an engagement session yesterday with us, together with Health Minister Dzulkefly Ahmad, on the proposed Medical Act amendment bill.

Yesterday’s meeting was a follow-up to our initial meeting with several members of the Health PSSC last July 3.

We take seriously Prime Minister Anwar Ibrahim’s note to the Independent Committee for the Review of Medical Specialist Training Programme 2023, chaired by Prof Emerita Dr Sharifah Hapsah Syed Hasan.

The Independent Committee Report has been classified as “confidential”, resulting in no opportunity for the report to be known or discussed publicly. However, Dr Sharifah Hapsah has informed that there is an important note from the Prime Minister that the solution must “follow the law”, meaning it must be based on the law.

The Independent Committee Report must be used in resolving this crisis involving the parallel pathway because the report indicates that issues can be resolved by following the existing 2012 amendment of the Medical Act 1971 (Act 50) and other laws.

Parallel Pathway Specialist Programme (PPP)

There are 14 PPPs, some of which have been registered in the National Specialist Register (NSR) through administrative processes, and another four PPPs that are not recognised by the Malaysian Medical Council (MMC).

The PPPs began with a Memorandum of Understanding (MOU) between foreign academies, the Ministry of Health Malaysia (MOH), and local medical specialist associations. These PPPs have been conducted without following the necessary governance and laws of Malaysia.

Compliance with existing law is necessary to ensure that all education programmes from within and outside the country, conducted in this country, are of high quality and that the medical specialists produced are guaranteed to be competent and safe.

Bringing in foreign programmes, controlled by the MOH – which are not recognised as specialists from the country of origin – results in unhealthy competition with local university programmes because their main source of students is from the MOH.

We hope that the Honourable Minister of Health will postpone the presentation of amendments to Act 50 in Parliament until a detailed study can be conducted, so that all doctors who have graduated from PPP and those currently pursuing PPP can be registered on the NSR without the need for amendments to Act 50.

Direct registration of PPP graduates can lead to the reputation of medical specialist training programmes in this country being looked down upon by other countries because no other country directly recognises these PPP graduates as specialists. It is also a betrayal to Malaysia’s local university programmes that have been in existence for the past 40 years.

Response to Statements by the Honourable Minister of Health

The PPPs were started in 2014 (after the amendment of the Medical Act in 2012), with authorisation by Cabinet decisions from 2014 to 2021. We believe no government will intentionally violate the law.

The non-compliance of PPP to the 2012 amendment of the Medical Act is as follows:

1. Conducting specialist programmes even though the MOH is not a Higher Education Provider (HEP); violating Section 2 of the Medical Act (Amendment 2012), and Section 2 of the Malaysian Qualifications Agency (MQA) Act 2007. It has also assigned specialist training tasks to associations, academies, and bodies that are not HEPs, such as the Malaysian Association for Thoracic and Cardiovascular Surgery (MATCVS), the Malaysian Urological Association (MUA), and the Academy of Medicine Malaysia (AMM); these organisations are registered under the Registrar of Societies Malaysia.
2. Conducting specialist programmes without complying with Section 4A(2)(h) of the Medical Act, i.e. not going through the programme accreditation process by the MMC, based on the recommendations of the Joint Technical Committee (JTC) established under the MQA Act. In fact, programmes with foreign qualifications (parallel pathway) are not recognised as specialists by the Medical Council of the country of origin. The Honourable Minister is insistent that accreditation is not a requirement.

In response to the statement, the FRCS Edinburgh (FRCSEd) programme has previously produced all Cardiothoracic Specialists and anyone who questions the safety performance of PPP Cardiothoracic Specialists is irresponsible:

For the record, FRCSEd graduates who passed before the Medical Act (Amendment 2012) had qualified as General Surgeons first. They were gazetted as General Surgeons and were in the NSR as General Surgeons before pursuing cardiothoracic subspecialty training through Apprenticeship.

After completing their subspecialty training and passing the NSR Cardiothoracic Evaluation Committee screening, they were then re-registered as Cardiothoracic Surgeons using the same NSR registration number.

Senior Cardiothoracic Specialists were more mature and experienced when they started their subspecialty training. It took them more than six years to become safe Cardiothoracic Specialists. The PPP Cardiothoracic training period is only six years and starts at the medical officer level.

Therefore, there is a significant difference between directly registering PPP Cardiothoracic graduates in the NSR and Senior Cardiothoracic Specialists. Direct entry into the NSR by amending the Act is an irresponsible action and could harm patients, our people.

The MOH has made its own interpretation of recognised training institution – confusing it with recognised training centres i.e. since MOH is not a recognised training institution, their training centres are also not recognised. This leads to the conclusion that the training exercise done in MOH centres for all PPPs and local Specialist programmes are not regulated, hence, justifying the need for the Act to be amended.

This interpretation is completely inaccurate. Act 679 involves the MQA Act for Higher Education Providers (HEPs). HEPs are Physical Providers that can have several specialist training centres that meet accreditation.

All specialist training centres, including MOH facilities, will be assessed during the accreditation exercise for the programme. Only training centres that pass the accreditation will be accepted as recognised specialist training centres. That is why accreditation is very important.

Currently, there are a limited number of Hadiah Latihan Persekutuan (HLP) and insufficient budgets from universities to pay honorarium to MOH Trainers or Clinical Training Personnel (TPPK), leading to a limited number of trainee specialists. The solution is to channel additional HLPs and for the MOH to help pay the TPPK honoraria.

The amendments proposed by the MOH are for programmes to undergo self-regulation and self-accreditation, and to put more MOH representatives in the MMC. It is dangerous to public safety when there is no legal oversight of PPPs on how a Specialist is trained and the programme is recognised.

The basis of regulation must be from an independent body. Reliance on individuals within the MMC or the Minister’s power – without being bound by the MQA Act – will open the way for abuse of power.

Existing regulations for entry into the NSR are clear that every Specialist needs further training after they obtain their qualification (mandatory post-qualification training). This takes one to two years after the degree is awarded.

The proposed amendment to the Medical Act mentions several Saving clauses for those who graduate from PPP to be directly included in the NSR, giving them the power to treat patients without supervision. This could harm patients.

The National Council of Women’s Organisations Malaysia (NCWO) – which represents over 200 women’s non-governmental organisation (NGO) groups – has expressed concern about proposed amendments to the Medical Act.

The NCWO wants to see only one set of standards and procedures in medical training — through MQA regulations which are followed diligently by all universities offering medical programmes in our country.

The public has confidence in this quality assurance process over the years. Why do we need to change just because some programmes are not following the law?

Recommendations

Yesterday’s engagement session with us at the Health PSSC did not discuss proposed measures to assist PPP trainees and those who completed the training WITHOUT amending the Medical Act. We strongly urge the MOH to comply with the law.

For PPP trainees who have completed training, consideration should be given to how they can be absorbed into local programmes through credit transfer processes and the like, this is in accordance to Section 74 of the MQA Act. Thus, they will be awarded registered qualifications in the MQR and eligible for registration as Specialists in the NSR. For trainees still in the PPP education system, they can be transferred to local university programmes through the same method.

The PPP must be under the Ministry of Higher Education (MOHE), with MOH’s participation as accredited training centres. This will resolve the issue with regards to recognised training institutions.

PPP must undergo the same quality assurance process as others i.e. comply in totality with the need for an independent accreditation process overseen by MQA.

Conclusion:

1. There is no need to amend Act 50.
2. Programmes with foreign qualifications must follow Malaysian law.
3. For our country to become a developed nation, we must play our respective roles, i.e. the MOHE as the Higher Education Provider and the MOH as the Health Care Provider.
4. We are concerned with the legal definitions brought by the MOH in justifying proposed amendments to Act 50. Therefore, we suggest that the judicial review concerning the graduate doctors of the Cardiothoracic PPP continue. Let the court decide.
5. We request that the Health PSSC inform the Prime Minister and MPs about the existence of the Independent Committee Report for the Review of Medical Specialist Training Programme 2023, chaired by Dr Sharifah Hapsah. We, representing the public from our respective organisations, wish to be informed of the findings and solutions from this Independent Committee.

We, the undersigned, Academics and Representatives of NGOs:

1. Dr Dayang Anita Abdul Aziz, National Council of Women’s Organisations Malaysia (NCWO).
2. Freida Pilus, National Council of Women’s Organisations Malaysia (NCWO).
3. Prof Dr Raja Amin Raja Mokhtar, Society of Thoracic Surgeons of Malaysia.
4. Prof Dr Zainuddin Wazir, Majlis Perundingan Melayu.
5. Prof Dr Tahir Azhar, Profesor G70.
6. Prof Dr Noor Hashim Ismail, G70.
7. Dr Zarida Hambali, Former Director, Higher Education Department, Ministry of Higher Education.
8. Dr Abdul Razzak Mohd Said, Former Member of the Medical Education Committee, Malaysian Medical Council.
9. Prof Dr Yang Faridah Abdul Aziz, Dean, Faculty of Medicine, Universiti Malaya.
10. Prof Dr Mohd Zamrin Dimon, Director, Hospital Al-Sultan Abdullah (HASA).

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