Let us talk about the sick Malaysian Healthcare. The sickness is the system? – Facts and figures

 

Recently there has been many write ups on what ails the Malaysian Healthcare system. There was much focus on the problems of junior house officers  and the toxic eco-system that junior doctors are working under. Politicians and NGOs were also concern about the “brain drain” of bright young Malaysian doctors who have migrated overseas, or some just over the causeway.

I have been watching the Malaysian Healthcare scene for the last 40 years, having work in the public sector, then the private sector, having taught in the public sector then the private sector and also having contributed to the some of the treatment methods currently in use in hospitals ( both public and private ). I would like to highlight the issues that I see as an outsider ( not in the Putrajaya eco-system ), and hopefully suggest some remedy.

“ Is the present Malaysian Healthcare sick”?

The answer is a big YES.

In the 90’s the Malaysian healthcare system was greatly admired by our peers. We were spending about 3.6% GDP on our healthcare and were achieving good healthcare outcome. We first started with one medical school ( UM 1962 ), then two medical school ( UKM 1972 ), then three medical school ( USM 1979 ).  3 medical schools in 17 years. Many of the junior doctors then were from local universities and the teachers were either expats from overseas or graduates from University of Malaya In Singapore.  Toxic culture among the juniors were unheard off and they were keen to learn with good attitude. The seniors were keen to teach. Hos/Mos and specialist got along well.

However since the 1990s, many radical changes took place. Under the PM 4 ( Prime Minister 4 ) administration, the sickness began, slowly but surely. I mean the deterioration of our healthcare system both in delivery of healthcare and also the outcome of healthcare delivery.

Since the beginning of 1990 till 2014 ( moratorium on medical schools ) we had an additional 33 medical schools of various sizes, most without their own teaching  hospitals ( sharing hospital patients with public hospitals ).

PM 4, having started the production of our national car, and decided that Malaysia was now an industrialised nation and should have the health standard of an industrialised nation. Political leaders began talking about having a national patient to doctor ratio of 1:600. Looks like this triggered the tsunami of medical schools and medical graduates. There was no concern about medical standards and quality. Only great concern about medical quantity. Not to forget that it was also a lucrative business to start medical schools ( remember PTPTN loans for students ). Ex-DGs of MOH upon retirement became Pro-Chancellor of medical school, one almost the next day after retirement as DG.

Sooner or later the poor quality was bound to show, and symptoms showed. When the symptoms became serious, there was public outcry and the first knee jerk response was a moratorium on medical schools effective 2014 telling us that they then realise there was a problem.

Symptoms of this ailing system.

The symptoms first began to show itself at the turn of the millennium when reports began to appear of poor standard of care in public hospitals. These were initially treated as isolated instances and dismissed.

Then things got worse and too serious to cover up.

Malpractice suits began to appear. We all the baby who ( born at Selayang Hospital ) suffered brain damage in 2005. The parents filed a law suit and won. Then there was the case of baby Yok Shan ( 2007 )  who lost her arm, when a doctor in Klang Hospital inserted an intravenous cannula into her arm muscle instead of her arm vein, causing her to lose her arm. The parents again went to court and won. These cases are mentioned as examples.  The Deputy Minister MOH told the press ( 2017 )  that annually, MOH received about 7,000 complaints annually and paid out about RM 20 million. The MOH 2020 annual report showed that in 2019 MOH paid out about RM 23 million in legal suits against MOH. ( Remember only those with money can afford to sue ).

The other troubling symptom is of course housemen bullying ( toxic work environment for junior doctors ). Absenteeism from work, downing tools at 5pm sharp became common. Junior doctors clocking out without reviewing their patients and without passing over ill patients to the on-call to care. Housemen  ( and even specialists ) bought clock-in  machines from on-line shops and were clocking in and out at will at home. There was even a case report of a housemen who was suppose to take blood from ward patients for investigation, who decided that he will take 20 cc blood from one patient and put them into multiple bottles labeled for other patients. And as a result of that houseman who committed suicide in Penang, and measures were taken by MOH to chastise medical officers and specialist who then became defensive. The pendulum swung the other way. Housemen have now become the “untouchables”, beyond discipline, even when they are clearly not doing their job, as the MOH has now given the right for housemen to complaint against their seniors. How then can the housemen learn and get trained when an advice and correction can be taken as “scolding”? Yes, there is a lot of training and corrections going on in the ward. Some seniors do abuse their position, but not the majority. Taking action that stops training and correction of junior doctors is counter productive and will show itself in badly trained junior doctors, which will translate to poorly trained medical officers and specialist and consultants. It takes time, but will eventually spoil the whole system. When you have poorly trained, incapable MO’s in peripheral hospitals, more cases get referred back to overcrowded district hospitals and state hospitals.

Of course the other symptom is the “brain drain”. Seeing the poor state of affairs in the public hospitals many young doctors seeing a poor career prospect, have chosen to vote with their feet, mostly to the English speaking countries and across the causeway. Many rose to prominent position  receiving outstanding awards and peer recognition. Their new country benefitted from our loss. There is shortage of data on medical brain drain. The Sun Daily reported recently that about 0.5 million skilled Malaysian ( all categories ) leave the country yearly for jobs overseas. Professor of Medicine of University of Malaya, tweeted recently that UM loses about 30 doctors yearly to Singapore. In fact Malaysians fill many of the top medical jobs in Singapore. This is also true for other professions and disciplines as well. 

Signs of this ailing system

I will use hard facts as the signs of an ailing healthcare system. These are hard facts on record, and not a personal opinion. I am talking about national clinical outcomes of our system, comparing our outcomes in 1990 and what they in 2019 ( before the onset of the pandemic ).The source of the data is also provided for all to check.

This is how we compare with our peers in the region. How they have improved compared to how we have improved. For Infant Mortality, our ASEAN  neighbours improve by double digits, we improve by low single digits. For life expectancy we improve at halve their rate. I could also use other indices which will show the same trend.

Then there is the index of medical litigation which reflects medical management standards not in keeping with community standards.  The Malaysian Medical Council ( medical professional governing body ) receives complaints and only investigate those complaints that have an ethical element, or an element of professional misconduct. They ask all who feel aggrieved by medical malpractice to seek redress through the civil court process. This cost money and the average B40 after losing their bread winner surely cannot get justice. How does the DG separate professional misconduct and professional negligence is surely a mood point? Anyway, I tried to get figures of professional misconduct, but such figures are not available. The MMC takes a long time to investigate a complaint ( may take years ) and very few doctors are found guilty by MMC, resulting in one reporter calling the MMC a protector of doctors, not of the people.  

Anyway, I did manage to find some statistics from the Annual MOH report 2020. ( shown below ). I was unable to find any record of litigation in the 90’s for comparison.

As we can see, we are paying out RM18 to RM 20 million annually for malpractice suits. Another sign of an ailing Healthcare?

Conclusion.

As can be seen from the symptoms and signs shown by our healthcare system, the system is sick and needs radical treatment, the sooner the better before it becomes malignant.

 The sickness is the system.