When we talk about retaining health care workers (HCWs), we usually ask: why are they leaving? Perhaps we should also ask: why do they no longer stay?
The two questions are related but different. People may leave because something pushes them away or because something better pulls them elsewhere. But people stay because there are reasons that make staying worthwhile.
To understand Malaysia’s HCW retention problem, we need to consider three things: the push factors from within, the pull factors from outside, and the shrinking pull factors from within the system itself.
Why Do They Leave?
There are many possible push factors: heavy workload, workforce shortages, fatigue, difficult working conditions, limited flexibility, concerns about remuneration, uncertain career progression and feeling undervalued.
Workplace culture matters too. Some workers may feel intimidated when they raise questions, highlight problems or propose solutions. Some may be scolded or corrected in humiliating rather than constructive ways.
Over time, people may learn that keeping quiet feels safer than speaking up. This matters because health care depends on workers being able to raise concerns, question unsafe practices and suggest improvements.
There are also external pull factors. The private sector or opportunities abroad may offer better remuneration, greater flexibility or different career opportunities.
Working hours outside government are not necessarily shorter or easier, but workers may feel that the workload and additional hours are better compensated, or that they have greater control over their working arrangements.
These external pull factors matter, but they should not become the main focus. Even if opportunities outside government disappeared tomorrow, would the problems inside disappear?
The workload, staffing shortages, career concerns, and workplace culture would remain. Closing the exit does not fix the room. The more important task is to understand what is pushing people towards that exit.
Why Do They No Longer Stay?
Government service has traditionally had its own pull factors: job security, training opportunities, career progression, professional development, institutional belonging and the value built through years of service.
But people weigh the whole package. HCWs have mortgages or rent, groceries, transport costs, children, spouses, and ageing parents. They need rest, financial security, good physical and mental health, recognition, and opportunities to grow.
Maslow’s hierarchy of needs offers a simple way to understand this. People need their basic needs met, followed by safety and security, relationships and belonging, recognition, and opportunities to fulfil their potential.
A secure job is valuable. But how much does that security weigh against rising workload, financial pressure, missed family time, poor work-life balance, limited career development, or a workplace where someone feels unable to speak openly?
People assess the risks and benefits of staying and leaving according to their own circumstances. When that calculation increasingly favours leaving, we should pay attention.
Stop Calling Them The ‘Strawberry Generation’
It is easy to describe younger workers as the strawberry generation — supposedly less resilient, more demanding, or unable to tolerate pressure.
That places the problem conveniently on the worker. Perhaps they need more resilience. Perhaps their psychological capital is poor. Perhaps they simply need to become tougher.
But before reaching that conclusion, we should ask whether the system has fulfilled its side of the relationship.
There is a concept called the psychological contract. It is the unwritten expectation that when workers give their time, skills, commitment, and sacrifice to an organisation, they can reasonably expect fair treatment in return.
Not luxury, but fair remuneration, reasonable working conditions, safety, support, respect, recognition, opportunities to develop, and some confidence that years of service will lead somewhere.
When workers repeatedly feel that they are giving more while what they receive does not keep pace, that relationship weakens.
Resilience programmes cannot replace adequate staffing. Psychological capital cannot replace sufficient rest. Well-being programmes cannot compensate for unfair working arrangements, humiliation at work or the absence of a credible career pathway.
Sometimes people do not leave because they are too weak to stay. They leave because staying no longer makes sense.
Is Their Time Being Fairly Valued?
Remuneration is part of this calculation, but the issue is broader than monthly salary. It is about whether payment reasonably reflects the time, responsibility, and restrictions placed on workers.
Take on-call duties in hospital setting. Instead of looking only at the total allowance, divide it by the number of hours a worker is required to be on call.
The effective hourly amount may tell a different story, especially when those hours involve clinical responsibility, disrupted sleep, nights away from family and sometimes returning to normal duties afterwards.
In a public health setting, officers may be rostered after office hours in an arrangement much like a passive call. They need to remain contactable and within a reasonable distance because an outbreak or urgent public health issue may require an immediate response.
It is not infrequent for officers to be contacted after hours, coordinate a response remotely or be physically present at short notice.
Even when nothing happens, their time is still restricted. Travel, family, and personal plans may need to be arranged around the possibility of being called.
Similar situations occur in other health professions, where workers may need to meet certain criteria before receiving standby-related payment even though they have already sacrificed some control over their time.
Being called to work and being required to remain ready for work are different, but both have value. If the system requires someone’s time to be reserved, that should be appropriately recognised.
What Happens When The Outside Looks More Attractive?
The remuneration difference between some government and private-sector opportunities can be substantial. Working outside government does not necessarily mean shorter hours or easier work, but the additional workload may be better compensated.
Government service still has important advantages, including job security, training opportunities and other benefits. But workers compare the whole package.
If remuneration increasingly falls behind alternatives, workload remains heavy, career development is uncertain, family time is repeatedly sacrificed and workers feel less valued, then the internal pull of government service becomes weaker.
At some point, job security alone may no longer be enough. The contract system may weaken this pull even further, particularly when employment security itself is no longer assured.
That brings us back to the second question: why do they no longer stay?
When One Leaves, Why Might Another Follow?
Retention has a domino effect. When a HCW leaves, the patients do not disappear. Clinics still run. Wards still need coverage. On-call rosters still need filling. Public health programmes still need to continue.
The work is redistributed among those who remain. An already stretched workforce becomes more stretched. Workload increases. Recovery and family time may decrease. Fatigue and frustration grow.
Those are the same push factors that may cause another worker to reconsider staying.
Then another person leaves, and the cycle repeats. HCWs leave. Fewer workers carry the same workload. Workload increases. Push factors become stronger. More HCWs consider leaving.
An existing human resources for health constraint can therefore worsen through poor retention.
What Does It Really Cost When Someone Leaves?
This raises another question: what is the real cost of losing HCWs?
When proposals for better remuneration, additional posts, revised allowances or improved working conditions reach policymakers, the immediate financial implications are understandably important.
How much will it cost? Can the government afford it? But those are not the only economic questions.
Malaysia has already invested heavily in educating and training its health workforce. The system has spent years developing clinical skills, specialist expertise, leadership, institutional knowledge, and experience.
When experienced workers leave, replacing the headcount does not immediately replace that experience.
There are also costs from recruitment, retraining, overtime, locums, service disruption and lost productivity. The additional workload placed on remaining staff may contribute to further departures, multiplying the cost.
Perhaps health economics needs to feature more prominently in the retention debate. Instead of asking only, “How much will this intervention cost?”, we should also ask: “Compared with what?”
What is the cost of improving retention compared with continuing with an already pressured system? Is maintaining the current arrangement really more cost-effective than providing HCWs with what they reasonably need to remain?
What If The Constraint Is Existing Policy?
Money is not the only constraint. Another commonly heard answer is that existing policies, regulations, schemes or circulars do not allow something to be done.
Rules are necessary, but policies can also be reviewed when circumstances change.
If an existing circular no longer reflects today’s responsibilities, workforce conditions or health-system needs, the conversation should not end with, “The circular does not allow it.” The next question should be: “Does the circular need to change?”
Goverernment officers and middle managers can prepare papers, provide evidence, and make recommendations, but they still work within financial ceilings, existing criteria and the authority available to them.
Sometimes a comprehensive proposal is gradually trimmed to fit those constraints. One component is reduced, another removed and another postponed. Eventually, the proposal may fit the rules and budget but no longer adequately solve the problem.
That is not necessarily a failure of the officers preparing it. They may simply lack the authority to change the boundaries.
Some problems cannot be solved by asking middle managers to prepare another paper. They require decisions from the level that can change those boundaries.
Why Leave? Why Stay? And What Are We Prepared To Change?
This brings us back to the title: why do HCWs leave? Because push factors accumulate and alternatives may become more attractive.
Why do they no longer stay? Because some of the things that once made public service worth staying for may no longer be strong enough to outweigh the financial, professional, family and personal costs of remaining.
That is why Budget 2027 presents an important opportunity. The response should not simply be another isolated allowance or short-term intervention. Nor can every workforce problem be solved through money alone. But saying “retention is multifactorial” should not become an excuse for avoiding remuneration.
Staffing, remuneration, on-call and standby recognition, career development, training, occupational safety and health, mental well-being, working conditions, flexibility, respectful workplaces, and supportive leadership all influence whether workers stay.
The issues are already known. Many recommendations have already been made. What may now be needed is the willingness to examine not only what can be changed within existing constraints, but whether some of those constraints themselves need to change.
Give HCWs what should rightfully accompany the responsibilities we ask them to carry. Not simply because doing so may help them stay, but because a health system cannot indefinitely depend on workers giving more while receiving fewer reasons to remain.
So before asking HCWs to be more resilient, ask whether the system is doing enough to retain them.
Before asking how much better remuneration and working conditions will cost, calculate the cost of continuing without them. And before asking why they leave, confront the harder question: what are we giving them to stay for?
Ultimately, this is not only about the welfare of HCWs. A supported, adequately staffed, and sustainable health workforce is essential to maintaining services, improving the health system, and, ultimately, protecting and improving the health of the population.
The author is a specialist doctor. CodeBlue is providing the author anonymity because civil servants are prohibited from writing to the press.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
