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Medicine is known for its notoriously difficult four to seven years of undergraduate studies, followed by years and years of training. It is rather accurate to state that this is all in hopes of a stable and lucrative future career, well, at least to the masses. As a Malaysian studying medicine in the UK, chances are that there is the dilemma of whether to stay in the UK or return home to practice as a qualified doctor. While both pathways may look structurally similar, their disparities could well influence the decision-making of medical students.

Qualifying in the UK

Eligible UK medical school graduates will join the two-year foundation programme as a foundation year (FY) doctor shortly after their medical degree. Upon completion, junior doctors will be registered under the General Medical Council (GMC) and are then eligible to train in a chosen specialty, which typically lasts three to eight years. There exists two main pathways here for different specialities: namely the run-through training for a one-off application uninterrupted training process, and the uncoupled training with a few years of core training (CT) before applying into a more competitive speciality training (ST) programme. After all the blood, sweat, and tears, successful trainees will finally be eligible to become a consultant on the Specialist Register under the GMC and are free to work under the NHS or, less commonly, join the private sector.

The other side of the spectrum, qualifying at home

On the other hand, a large proportion of aspiring Malaysian doctors would wish to practice back on home soil. Medical graduates will join the two-year foundation programmes as a house officer (HO, equivalent to FY) with criteria similar to that of the UK system. However, waiting time to be offered a position can be slightly longer (some wait for up to a year) due to a lack of training vacancies and an oversupply of medical graduates (~6000 annually, from a total of 32 medical schools nationwide). Junior doctors will then proceed to become a medical officer (MO) in the public sector for a few more years. MOs who want to specialise typically go into the local master programmes provided by selected local universities, under a full scholarship called Hadiah Latihan Persekutuan (HLP) provided by the Ministry of Health (MoH). Alternatively, they could choose to do a self-funded parallel pathway with external exams from recognised institutions involving a 4-year logbook period and 18-month gazettement period at the end of the programme. 

So what is the problem, and why #HartalDoktorKontrak?

Since 2016, the government has implemented a new contract system for medical graduates who have waited for far too long to get a placement. Under this scheme, medical graduates would be hired as housemen on a 5-year contractual basis, i.e. 2 years of HO and 3 years of MO. The catch here is that only permanently employed MOs are eligible for the local master programmes and there were only about 1000 positions available across all specialities for 20,000 of MOs annually. Furthermore, while the parallel pathway provides greater leeway for specialisation, the hefty price tag and lack of study leaves may not be realistic for all the MOs. Having that in mind, contract MOs have insufficient time (due to the compulsory 4-year logbook period) to complete the parallel pathway prior to the conclusion of their contracts. 

As of July 2020, only about 3.3% (665/19909) of contract medical officers were absorbed as permanent MOs, leaving 96.7% having to find their own way to navigate through the healthcare system as the first batch of contract system ends in 2021. 

The Strike

Amidst the critical situation of the pandemic in Malaysia, the concomitant defects of the contract system for medical graduates have been highlighted in light of the recent #CodeBlackMy and #HartalDoktorKontrak movements which have run rampant at breakneck speed. Apart from an unknown future, they are also suffering from various issues, namely lack of transparency of selection criteria for permanent posts, job insecurity, and inequality in remuneration and benefits. In addition, these are exacerbated by the pandemic cloud in the country as doctors have been significantly overworked with overcrowded health care facilities and an elevated risk of contracting the infectious disease in our already vulnerable health care system.

#CodeBlackMY was therefore initiated by the Malaysian Medical Association (MMA) Section Concerning House Officers, Medical Officers, and Specialists (SCHOMOS) as a measure to call for urgent actions taken by the Federal Government to resolve this critical issue. Under this movement, SCHOMOS demanded a clear career pathway for contract medical officers, fair opportunities and compensations as well as a better transparency of selection criteria for permanent posts. As a result of this online protest, the December 2016 batch of contract medical officers have been offered a one-year contract extension by the Health Ministry instead of permanent posts, which undoubtedly fails to address the underlying issues. 

Faced with immense pressure due to the termination of the contract at the end of the year, a group of medical officers have concocted the ‘Hartal Doktor Kontrak’, a nationwide strike that happened on 26th of July (Monday) as the government had then yet to propose a permanent resolution. In response to the planned strike which has gone viral on social media platforms, the federal government came up with a plan which includes 2 to 4 years of contract extension as well as giving similar opportunities for contract medical officers as their permanent counterparts. According to the ‘Hartal Doktor Kontrak’ group however, this only serves as a seemingly promising measure which is short-sighted and intended to sugarcoat efforts to ‘keep the group quiet’. As of the latest updates from both the government and the ‘Hartal Doktor Kontrak’ group, the nightmare for all contract medical officers has yet to be satisfactorily and properly mitigated.

Moving forward, what will the country face?

Why should all Malaysians care at all? Why would it even cross anyone’s mind to mess with a country’s healthcare system? Whilst there might not be an immediate observable effect caused by the contract system, this will no doubt take a toll on the healthcare system of Malaysia in the long run – very likely due to brain drain. Should this chaos persist, we will be faced with a dwindling supply of well-trained and experienced medical specialists, the effects of which can be manifested in just a couple of years. Oversupply of medical graduates, severe lack of medical specialists, and lower-than-peer healthcare spending are but some of the pressing concerns that need immediate attention from the government.