Patients lie in various conditions on stretchers, wheelchairs and on the ground, some outside the hospital’s lobby. This is not a war zone, but rather the work environment for the 23,000 contract doctors working at Malaysia’s public quarantine centres through the ongoing Covid-19 outbreak that has accelerated since June.
“My hospital has an emergency department that is horrible,” one contractor in west Malaysia told the Globe, asking to go unnamed. “We don’t have places for patients to be put … some of them who require oxygen, IV drips or medication are put in the decontamination area, the area usually patients come to because of toxic exposure.”
That contractor is one of three anonymous doctors currently working in Malaysia’s quarantine centres who recently told the Globe their wards are understaffed and under-supplied, run by doctors employed through tenuous contracts that leave many feeling burnt-out even in more normal times. Unlike their permanent doctor counterparts, contractors typically do not have annual leave, are often paid less, do not receive government funding for their specialisation, and can be dismissed at any point during their contract.
Late last month, during the week of July 23, as many as 8,000 contract doctors in public quarantine centres conducted a work strike organised by a grassroots network known as Hartal Dokter Kontrak, or Contract Doctor Strike. Founded as an organisation just this year, Hartal rose to prominence during the pandemic and is now calling for better conditions for contractors during and after the Covid-19 crisis.
The strikes in facilities mostly in West Malaysia have sparked a wider conversation about the lack of job security and the exacerbated emotional toll of working in Malaysia’s public healthcare system, upheld by contractors who say their grievances are typically hidden behind stacks of bureaucratic paperwork. The demonstrations have attracted the attention of politicians, who are now discussing amending the country’s broad 1980 Pension Act in order to address some of the contractors’ struggles. Still, it remains to be seen how the concerns of exhausted contract doctors will be addressed as the pandemic grinds on.
Dr Yassin, who wished to go only by his first name, is a medical officer in a quarantine centre in the state of Negeri Sembilan just south of Kuala Lumpur. Along with his wife, who is also a doctor, he has been working in public healthcare for three years. Although he did not participate in the strikes because he had contracted Covid-19 while on duty, he used social media before the demonstrations to raise awareness about his plight and that faced by contract doctors.
Yassin estimated that contractors represent about 70-80% of the doctors working in Malaysia’s quarantine centres, manning 12-hour shifts on a daily basis. He told the Globe he supports the Hartal movement because of his job insecurity and heightened exposure to Covid-19.
“I just recovered from Covid two days ago. My wife also got Covid last week, although we are vaccinated we still have a higher risk of being infected because we work with patients every day,” Yassin said. “We always think of our families because they may not be vaccinated or are older than us.”
Malaysia’s Ministry of Health established the contractor system in 2016, partly as a means to create new trainee placements for medical school graduates while also managing financial constraints on the public healthcare system. Hiring permanent doctors is costly because each position guarantees a regular salary, job security and additional pensions.
The move to hire contractors came at a time of mounting public expenditures. Across all public positions, the Malaysian government nearly doubled annual spending on pensions and salaries between 2011-21, increasing from $10 billion to $19 billion. The Health Ministry is no exception to this trend. Though its current permanent workforce of 267,733 people is smaller by about 1,000 than in 2016, the ministry is now spending approximately $800 million more for compensation than it was five years ago – a total today of about $4.03 billion.
According to Edwin Goh, a researcher with non-partisan policy think tank The Centre, much of the recent increase is due to compensation for a growing cohort of contractors, who now make up about 11% of the Health Ministry’s spending for salaries and benefits.
Still, that cost would be much higher if they were permanent staff. The Centre predicts an annual additional cost of nearly $472 million to convert all of the public healthcare system’s contract doctors into permanent staff with pensions.
“Essentially, hiring contract workers enables the government to pay a smaller portion of entitled pensions to the doctors compared to those with permanent positions,” Goh said. “On the other hand, it helps the government deal with how medical graduates enter the workforce.”
The first wave was not too bad. But as time progressed, I was deployed to another state, I had to go to the hospital and started off with a whole block of patients
Though contract hiring may help defray expenses for public health, the practice also allows Malaysia’s overwhelming surplus of medical students to fulfill their licensing requirements after graduating from medical school.
According to Goh, the country’s 31 medical schools produce as many as 6,000 new graduates per year in need of placements. Under the Medical Act of 1971, all medical school graduates looking to become licensed practitioners in Malaysia must complete a residency and train through service at government hospitals, a step that may take about two or three years.
But at present, many of Malaysia’s contract doctors are fully licensed doctors who have completed their public service requirement. Natasha, a contract doctor with five years of medical experience, told the Globe that contractors have also been routed to the front lines of the Covid-19 response. She’s been working in a quarantine centre since the first novel coronavirus outbreak in March 2020.
“We were deployed to the Covid wards initially, we started off with a minimum of 60 patients. The first wave was not too bad. But as time progressed, I was deployed to another state, I had to go to the hospital and started off with a whole block of patients.”
Natasha said her hospital currently has just one doctor for every 200 patients as daily cases rise. The tight staffing amidst a rush of new infections has left her and other contractors to fight their own mounting fatigue without structured rest days.
“Burnout is like a daily thing. When we go to work and come back, I am mentally exhausted. My family asks how things are, I don’t wanna talk anymore. You deal with a lot at work. There is no proper work-life balance.”
Her perspective is reinforced by the fact that more than 50% of Malaysian medical staff have experienced burnout during the pandemic. Natasha believes contractors are even more likely to hit the wall as they are placed where needed – in the current health crisis, this means directly encountering Covid-19 patients.
But even though contractors have shored up many of the gaps in the public healthcare system before and during the pandemic, they’re finding little way forward to being recognised as permanent employees with full benefits.
From 2016-21, only 789 of the 23,000 contract doctors in public healthcare were given permanent positions. The Health Ministry published a statement about a month before the July protests explaining the widening ratio of contract doctors to permanent doctors, stating the ability to hire permanent roles is restricted by a set level of vacant positions. That dynamic isn’t likely to change anytime soon, the ministry stated, meaning medical graduates might be better suited to find permanent work in other healthcare fields beyond the public sector.
However, Malaysia’s Director General of Health Dr. Noor Hisham Abdullah also stated in June that his office was looking into converting contractors to permanent medical positions. More immediately, he urged doctors to remain patient as a task force investigates solutions such as extending two-year contract extensions – a suggestion typically met with an unenthusiastic response from the contractor population.
For now, the rapid expansion of Covid-19 seems to be outpacing that problem-solving process. In July, it was reported that 163 contract doctors had resigned since January in Selangor state alone. Although there were various reasons behind their resignation, pressure and emotional burnout were cited as predominant concerns. This trend correlated with Malaysia’s rapid increase of daily Covid-19 cases, an upward swing from 1,400 per day in March to 17,000 in July. In late July, total cases passed the 1 million mark.
A lot of people do not recognise Hartal. We are not a group, association or nonprofit. We are just a movement. We want to move towards a union
Lissa, a contract doctor working at a Health Ministry hospital and an organiser within the Hartal movement, told the Globe that prior to 2016, all medical school students within the public healthcare system were guaranteed permanent positions after graduating. But introducing contractors in 2016, the Health Ministry started using more ambiguous criteria to fill sparsely available permanent positions.
Now, the Hartal movement aims to raise public awareness of how underpaid and overworked contract doctors are compared to their permanent counterparts, especially during the ongoing pandemic. Lissa says it is now looking into official unionisation to pull issues such as higher pay, access to annual and study leave, and a more transparent path to medical specialisation into the public discourse.
“We think it would benefit us more if we create a union,” she said. “A lot of people do not recognise Hartal. We are not a group, association or nonprofit. We are just a movement. We want to move towards a union.”
Although the Malaysian Medical Association (MMA) legally represents contract doctors, both Yassin and Lissa were concerned about the lack of communication between the body and contractors. According to Yassin, in the past, permanent doctors appointed as MMA leaders had direct contact with government officials when discussing public healthcare issues, but they seldom asked contract doctors about their needs.
However, with the pandemic bringing contract doctors’ struggles to the fore, there are indications this may be changing. In June, MMA honorary General Secretary Dr Thirunavukarasu Rajoo published a press statement amplifying many contract doctors’ concerns, such as the need for clearer paths to medical specialisation. Rajoo also emphasised that contract extensions are not feasible as a long-term solution to staffing issues.
Although distancing itself from the Hartal movement, the MMA in July also launched an alternative initiative known as Code Black to show solidarity with contactors. Its initiative was pushed to discourage medical contractors from striking because they feared the disruption of public healthcare services in quarantine centres. From July 1 to 12, the Code Black campaign urged permanent doctors to wear black and hold placards bearing the slogan, ‘We stand with healthcare workers’.
The MMA did not respond to the Globe’s requests for an interview.
But without actual solutions, feeling alienated and echoing similar frustrations as her colleague Yassin, Lissa still believes it will be important to unionise all contract doctors in order to negotiate directly with the government.
“We have come to realise that we have to rely on ourselves to push the issue further,” she said.
One step to improved rights might come from the political arena. Malaysia’s Pension Act of 1980 administers how civil servants, including healthcare workers, receive their benefits and permanent job positions. By amending the act, the government could provide the latter to contractors. Though that would be a step in the right direction, contract doctors told the Globe there should be more transparency about financial constraints in the public healthcare system.
Still, Lissa doubts the Pension Act will be reformed quickly. She told the Globe the Hartal movement is considering a second strike, slightly different from the first one, if politicians fail to make any substantive changes soon.
While some contractors leave the public system, seeking security in the more lucrative private medical sector, many still find their calling in public medicine. Yassin believes he and his peers do it to care for the collective health of the people.
“Most of us want to serve the nation,” he said. “The nation really needs us.”