For Future Doctors: Malaysian Healthcare System for the Dummies Part 1
Recently I came to know that many, especially medical students and junior doctors are unaware about the healthcare system of our country. No doubt that the Malaysian healthcare system has been commended by WHO as one of the best in terms of accessibility and affordability. I do not dispute that, but we are still running at the same pace and concept as of 50 years ago. There are many things that are changing but Malaysian healthcare system seems to be either stagnant or moving backwards in certain aspect. Our politicians seem to be saying the same rhetoric over and over again the last 40 years with a delusion of world-class healthcare for all! Quantity is not equivalent to quality!
I will divide this topic into the public and private healthcare. The public healthcare is divided into the hospital based (clinical) and the public primary healthcare which consist of Klinik Kesihatan, Polyclinics, Klinik Desa, 1Malaysia Clinic and the public health departments. I will finish these series with the problems and limitations of our health care system.
Public Primary Healthcare
Klinik Desa
In terms of accessibility, our public primary healthcare is one of the best in the world. Almost any person has an accessible healthcare within 5-10 kilometre radius. Even the most rural areas are covered by Klinik Desa. Klinik Desa (KD) is run by Jururawat Masyarakat (JM) and it is basically a Women and Child Health clinic. It is meant for uncomplicated antenatal and post natal follow-up as well as vaccination. The JMs are usually trained to pick up any signs of complicated pregnancies and referred to the nearest Klinik Kesihatan (KK) which has a doctor. The JMs also does home visits for antenatal and postnatal mothers. These Klinik Desa are not meant for anything else.
Klinik Kesihatan
There is usually one Klinik Kesihatan in each small and major town. Many years ago, almost all of these Klinik Kesihatans were run by Medical Assistants (MA). I must say that the MAs those days are not like some of our MAs now. They were a dedicated lot and know how to manage emergencies better than our current batch of junior doctors. They are allowed to treat Hypertension, Diabetes mellitus and simple cough and cold. That’s the reason the hypertensive and diabetic medications were categorised under Class C. Even though most of these KKs are now equipped with Medical Officers (MO), the situation has not changed much. The good quality MAs have all retired or going to retire. The MOs are usually those who have just finished housemanship. The quality of care has not improved much, I must say.
Most KKs have at least 2 MOs nowadays. Unfortunately, most of the time, these MOs are used to run the Antenatal clinics. The general outpatient clinics are still run by MAs and with the current quality of MAs, many serious mistakes are being made. Some of these MAs act like they are doctors and do not ask anything concerning the management of the patients. Some MAs still think that a Fasting Glucose of 8.0 is good enough for diabetics! The MOs only help to run the outpatients clinics about 1-2 times/week. Since the MOs have got no proper supervision, many mistakes that are committed goes undetected. In fact many serious mistakes and mismanagement are being committed on a daily basis. Some MOs also make use of the system to their advantage. I know of many who degrade the medical profession with their attitude so much so that even MAs and Staff nurses do not respect them. Going missing in the afternoons, taking emergency leaves without submitting any leave form and asking MAs to cover their clinics etc. is something that happens in smaller KKs throughout the country. Unfortunately no action can be taken against them as they are the boss of the clinic!
Some of the KKs in major towns have been converted to outpatient polyclinics over the last 8-10 years. These polyclinics are only meant for general outpatient clinics and some of them may have up to 8 MOs running the service. The MOs are usually involved in only running the outpatient services but the workload depends on the number of patients who are visiting the clinic per day, some even seeing about 150 patients a day. Even in these clinics, MAs do run a clinic to see the patients. These clinics usually have their own lab and Xray services for basic investigations.
Lately, over the past 5-6 years, some of these KKs, especially those nearer to bigger towns have Family Medicine Specialist (FMS). Unfortunately, some of these FMS are not doing their job. Many of them do not see enough number of patients and do not provide CME or trainings to the junior doctors or staffs of the clinic. Thus, having FMS in many of these clinics do not add any improvement in quality of care. The MOs are still left unsupervised. Lastly, many of these MOs in KK are not just running clinical services. They will also be involved in health education, school visits, managing outbreaks etc. There will also be a lot of administrative work to do as you will be the head of your clinic. You need to plan and carry out various health related programmes especially those instant projects that our great politicians usually come up with!
At the same time, we should not forget the Public Health Officers or Pegawai Kesihatan Awam. These are doctors who do not do any clinical work but works in the health office doing mainly administrative work. Some of them possess Master in Public Health (MPH). These doctors are purely involved in administrative work in developing various programmes and monitoring infective outbreaks and controlling infective diseases like Dengue, Typhoid and Malaria. They play an important role behind the curtain.
I must bring up certain issues regarding working in KKs. As a MO in KK, you are not allowed to prescribe medications that are listed as List A drugs which include most of the antibiotics and hypertensive drugs. For example, you can’t prescribe Amlodipine for hypertension as it is still considered a List A drug. Unless the FMS prescribes these medications, you will not be able to prescribe. When I was working in a district, the only antibiotic that I could prescribe was ampicillin, bacampicillin, amoxycillin, erythromycin, penicillin and gentamicin! I believe the situation is still the same except for KK which has FMS! Well, for your information, a patient only needs to pay RM1 for consultation, investigations and medications in these KKs! The rest are paid by tax payers’ money. Thus, I don’t aspect any better quality treatment from these clinics. As I have said, we are still living in a system which is more than 40 years old!
Finally, one good thing about working in KKs is the fact that you only work office hours and rarely called after office hours except during outbreaks/floods. This gives you a lot of time to prepare for any exams that you intend to sit such as MRCP/MRCS Part 1. And, by the way, your salary is the same as any other doctor of same seniority working in any other hospitals. Again, as I have said before, if you intend to specialise, please do not stay too long in KKs as it will make you complacent and lose the momentum to pursue your studies!
1Malaysia Clinic
In Budget 2010, our beloved Prime Minister proposed 50, 1Malaysia clinics to be started in semirural and urban areas to cater for the urban poor. Another additional 30 clinics will be introduced in 2011 as they claim that the first 50 was a success. We all know that this is a political stunt to win votes.
This 1Malaysia clinic is a regressive approach. We should be moving forward and not backwards. As you will be well aware that these clinics are run by MAs from 8am to 10pm every day. It was meant for common cough & cold, dressing and minor ailments. However, looking at the standards of our current generations of MAs, I doubt the quality of care that is being provided. Furthermore, anyone can walk into these clinics with complaints that a MA may not be able to diagnose a nd may very well miss an important diagnosis. Well, when we have doctors with questionable quality nowadays, what more with MAs!
So, in Malaysia, after 54 years of independence we still have MAs running clinics with the status of a doctor! When the government insist on GPs to abide with the Private Healthcare and Facilities Act 1998, the government itself is not adhering to the standards. Talk about leadership by example!
Next………………….. hospital based public health care system
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PARTIALLY TRUE. writer shud go hv a visit in current kk and then comment on it. theres misunderstanding towards work in kk, and please must hv a close involvement in its daily work before commment on anythng. one tree is not equal to whole forest.
first , not all MO in KK is not experienced.most of them are not even new MO who were sent to cover the area immediately completed housemannship. As the old batch of MO who stick to previous principle of 1 & half year services was even sent out to KK after started practising in certain subspeciality in hospital , as it was not approved by KKM/JKN after their services
not all MO will only work 8 – 5 then locum KING/ studying. the point that they got enough time to study for external paper exam is not equal to lack of experience, at least that person had basic knowledge compare to the group (new generation)which did not show self improved.
but I did disagree of MO in KK being locum King and not able to give full concerntration on work the following day and as writer said, action must be taken towards them.
SECOND ,
if writer really did a survey of all the KK/ OPD in our country , not all KK is relaxing and shacking leg in doing job. did the writer know that number of patient in 1 morning? a session in OPD /KK may reach 130 patient and our very considerate government setting up an KPI system of waiting time not more than 30 minutes for each patient turn . number of MO / session =2 to 3, some even 1 MO reviewing patient the whole session .
MO in certain KK not as the writer said only stand by in OPD/KK twice a week . currently , it the opposite way round. I do agree with the writer that few problematic MO which MIA/unresponsively taking EL if present throughout the country but the writer must think on the bright site. do u know that there’s few MO that not even manage to get leave months due to a no answer from PKD in their application because have to cover for the shortage from the above group have done.
third ,
medication in list A group cannot be started in KK / OPD . correct agree with writer. but did writer aware that some of the medication mention in the article was actually being started from hospital. KK just continuation from the hospital . some of the patient was giving different history and medication profile when seeking treatmetn in KK and few weeks/months later told differrently in bigger hospital. furthermore, there’s cases that big hospital prescription of medication which was not even available in KK . they actually cursing MO KK not giving the medication but who to blame ?? its the hospital personal that requested them to f/up taking medication in KK
I think you are not getting the point. I did not blame or accuse anybody in this article. It is just a general overview of the public healthcare system in Malaysia. No where in the article I said that MOs in KK are shaking legs!! Please read again. In fact I said that the MOs have a lot of work to do including administrative work etc. I think you should read the article as a whole rather then each sentence!
Yes, I do agree that there are senior MOs in KKs but generally these senior MOs will be transferred to do administrative work as part of their promotion, later on. So, most of the KKs are still run by junior doctors , usually 2-5 years of service. Some leave to do Master’s after 2-3 years in KK.
Did I say anything about prescribing List A drugs that was offensive to the KK doctors? I did not! I am merely stating the fact that KK MOs are not allowed to prescribe any List A drugs unless it is approved by a specialist. Many do not know this fact! So, please, read my article carefully! and Yes, once the drug has been started in GH, it can be followed up at KK. The KK should make the attempt to get the drug for the patient as long as it is in the Blue Book.
Finally, some of the issues you are talking about , I am well aware. My wife has been working in KK for 13 years. But as I said in my second paragraph, I will talk about the problems and limitations with our health system in my final part!
And, I think you should inprove on your English! I don’t seem to understand some of your sentence!
I would hasten to add that I support the idea of Family Medicine Specialists in our health system. I personally think that the Postgrad Diploma should be made compulsory for anyone wanting to be a GP (FMS have Masters). Just because you have done your stint in the govt, it doesn’t mean you’re qualified to be a GP. Some form of certification should be required and General Practice / Family Medicine should be recognized ad a specialty in its own right.
There are of course consequences to this. GPs who can manage their patients well may affect private physicians ( less referrals, same reason private hospitals don’t hire Emergency Medicine specialists).
On another note, The FMS in govt clinics should be doing their bit to teach MOs attached to those clinics and provide clinical oversight to everyone working there.
Dr Paga, It would be great if you could do a write-up about the 1care national health financing system. There seems to be a lot of secrecy and hush-hush in its implementation, and growing rumours suggest that top guns in putrajaya are trying to establish businesses to take advantage of the streamlined pharmaceutical dispensing, bread and butter diagnostic procedures as well as administrative processes, before the system goes on-line.
The shining light so far is that Acad Family Physicians Malaysia seem to be playing a strong role in defending the gp boundaries, and so far Inderjit Ludher and Dato’ Thurai are doing a good job.
Much better than MMA.
No one knows in detail about this 1Care system. What I understand is that it is an intergration of GPs and public primary health care system. This will be implemented in stages starting from 2014 and after fully implimented, they will procede to hospitals, probably will take another 10years !
I think, David Quek did write about it in Berita MMA few months ago, quite in detail.
Another question which intrigues me.
You said that your wife has been in KK for 13 years. I really really want to know, why is she in gov service? She can easily switch to private services right?
I guess my question is, why do gps stay in KK despite getting ‘better’ offers in private? Besides getting tied down with scholarships/masters, of course.
Well, she was about to start her Master;s in Family Medicine when her father had to undergo CABG for unstable angina and at the same time I had to go to UK for my MRCP Part 3. So, she postponed her studies but never manage to restart as she was also pregnant with 3rd child. Currently she is doing her FRACGP training, completed Diploma.
dear Dr Paga,
i have been following your blog with great interest due to the many issues that struck very close to my heart. thanks for voicing up so many important matters.
Just wondering if you mind sharing more about the FRCGP that your wife is currently doing. Is it the continuation for the diploma offered jointly by our local academy of FP with Australia?had enough nonsense from the ministry, better to make plans and fend for ourselves rather than hoping the ministry will give me what i deserve.
thanks in advance.
Yes, the MOH only agreed to recognise FRACG if it is a 4 year programme and thus the AFPM had to make it a 4 year programme with Diploma in between. After the 4 years , you can sit for the exams.
Ali, what are the ‘nonsenses’ you are facing?
No offence, but your name is not Andrew, Anba or Ang Lee.
No, seriously, don’t take this as a rascist comment, I am very curious to know what is your perspective of the situation..
chillax ur funny..
Thanks Dr Paga.
Dear Chillax, a name is just but a name. You dont sound all that ‘chilled’ either. when you have been worked voluntarily in a distant state and served the most rural district hospital in the country,only to be deserted by the very own health system that you served for, and later being transferred to deskjob against your wish after so much of hard work and sacrifice, and to be told that ‘experience in a borneo district hospital’ is not taken into account as experience; then you can come and ask me about my ‘nonsense’ again, haha!
remember a name is just but a name, we have all been through the ‘kulit’fication system.
aah.. see this is what we need…
We need ppl of all races to reject corruption and poor governance. I am not saying that BN is corrupted and a poor government. I am saying it exists everywhere, and the most competitive countries in the world consist of people who systematically and maturely reject bad governments.
We Need To BE THAT.
Btw, ali, i agree wit you..a name is just a name..
Read this from NST …
http://www.nst.com.my/nst/articles/2educ/Article/
Dear Dr Pagal..
Thank for the informative and interesting blogs..appreciate your candor and honesty.
Sometime back you wrote an interesting piece on the Public Health Specialists.
I have just completed my Masters In Public Health (MPH) and am continuing with my Doctorate In Public Health (DrPH) which we are required to do in order to be recognized as par with the clinical specialists now.
Some of the points you highlighted are so true..Remember working around the clock as one of the officers in charge at KLIA during the recent H1N1 scare..and many countless other operations..we don’t get credit and go under the radar for every success but get bad publicity whenever things go wrong..
We are the mercy and whims of politicians when they decide to interfere with our jobs.
We work hard to reduce admissions into hospitals for later stages of a disease by stressing on early detection and management or preventive measures.
Working in the field of Communicable Disease control..I have come to know many a great Public Health Physicians who have given so much to the public health care system..
Even though we don’t see patients on a day to day basis..when one’s deals with diseases ..our clinical knowledge must be on par with the clinicians..coupled with the public health component..for both national and international platforms. Many a times we have dealt with health agencies from other countries too.
Thank you for your kind words and acknowledgement..Normally it is the other way around..we get to meet arrogant primadonna clinicians who think the world revolves around them..So it was a real nice to read your blog.
I have a question..if you can help me with..any prospects for us to work abroad ?
I met some friends from Africa who have the MPH from UM ..they have told me the propects of working in the middle east is good..
Being a non muslim..not so keen to over there..as preferences are given to muslims..
Any idea on Australia ?
I know we can get assimilated in to WHO but working with them before..you need to have a singleton’s life to excel over there..
Thanks again for the information and please keep it up..
Have a nice weekend..
Thanks for the compliments. Master’s degree from Malaysia is not widely recognised except for some middle east countries. Australia do not recognise any of our degrees and thus finding a job in Australia may be difficult. You can still try if your field is an area of need in Australia. You can go throu the AMC website.
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Do you have one good suggestion to improve the current primary care in the country?
I bet you don’t. Neither do I.
I admire your general overview and feeling about the our present healthcare system. I have many similar feelings when I was reading your writing.
You are quite right in saying it has not been progressing in tandem with modern practice. You are also quite right about the 1Malaysia clinic being kind of regression instead of progression in current medical practice, being political gimmick etc.
Are you in tandem with primary care transformation in these past few years? If you do, you will be shocked with the strides (both positive and negative).
Do you have any idea of what are the principles of family medicine/primary medical care? If you do, you would honestly respect the primary care physician/FMS who are holding their ground.
Do you know the general characteristics of patients attending a KK? If you do, you would cry, either for being grateful you are not working in primary care or for not being primary care physician.
Do you know the relationship between the public health and KK? If you do, you may find the answer to the opening question of my writing.