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
then why Dr dont fill up the position at klinik desa? i hve work both hospital n klinik.there lot of dr at hospital. icu itself there are more than 10 dr. tranfer them la. so i dont have to carry their work load. im not acting like MO. im doing my job as much as i can still in my SOP.
KLinik desa are not meant for doctors. There is no post for doctors in klinik desa. it is meant for jururawat masyarakat for antenatal, postnatal and child health care.
I presume you are talking about klinik kesihatan and polikliniks! soon, all klinik kesihatan will be filled with doctors. it is already happening in many states where the post for MOs in klinik kesihatans are full. Soon MAs will be running clinic 1Malaysia only and probably A&E departments in hospitals. IN KK, they might just be doing some admin work and assisstant work rather than seeing patients.
nope.. nowadays Klinik Desa will fill up with MA again. same like MA’s more than 100 years ago. pilot project.. MA will working with JM. bcause there are no need for MA to work at klinik kesihatan. there are 200 patients a days with a lot of dr. at my area klinik kesihatan is fill with 5 MO. better quality than before. i hope. which is each MO will look about 20 patients a day. beside there is FMS.
you know why thid is happening right? Soon, infact it has already started, there will be oversupply of doctors . MOh has already started to give housemanship on contract basis and not permanent civil service. All those who have finished HO are being sent out to kk, district hospitals etc. KLinik Desa got no MO post and thus doctors cannot be sent there. Since most KKs are being filled with MOs(doctors) now, MAs will likely be sent to klinik Desa.
It lookes like MOH has just screwed themselves up with so many medical schools in the country, the highest percapita population in the world. Furthermore, 50% of these medical schools are yet to produce their graduates!! Who knows, soon they may send MO to klinik desa and klinik 1Malaysia. MAs might be out of job like what is happening to nurses nowadays, just before doctors become jobless.
now MA’s dont know what to fight for.. just like before.. im one man show in KK that had 150 patients a day. in that time i hope there will be a MO that can support that. finally theres a MO. but one more coming n coming. i was thrown away. like nothing. now i got KD soon my KD will run Bigger n bigeer. then i know some day i’ll thrown away like the older time. but what im doing is better service for tomorrow. MA will jumut one day n no one will know that MA was running clinic before more than 100 years before dr.
YUp, I do agree. MAs were the backbone of Malaysian health care for many years. I know of many good MAs who managed KKs and emergency departments those days. I learned a lot from them when I did my district hospital postings. Unfortunately, as what you said, it may become jumut soon. When doctors can become jobless after spending almost RM 500K, why the government going to be bothered about MAs? they will just shut down the training centres and wait for all those in service to retire.
Our human resource planning, which I don’t think we have any, has gone to the drain.
yeh rite.. but what im think is. why not they offer this MA for further study in medical it self.. too many of youngster of MA’s. and a lot of female MA’. then shut down the college of MA’s. those MA’s that dont want to cont their stdy wait till retire. this MA know a lot about this field and think if they have a degree of medical what quality they will give?
i have work at KK alone.. very low ffacilities.. no lab tech nician. and 1 pharmachist assistant.. i have to take a lot of time to make an impression. viral fever. i have to do it below microscope for early lab result. i have to stain tb slide my self. do ecg and make impression. when im refer it to poliklinik or GH. the MO will asking me. what the diagnosis. how should i tell them? inferior MI or heart disease. im not an expertise of ecg but i know how to read it. all from the basis. how to auscaltate, how to percuss and how to make a simple examination. but diagnosis? if they ask me, eventhough i know. i will never give it. just my impression… still being scolded. im prefer to continue my study but there is no such a relevance bachelor for MA. medical school. they diont approve MA for this study… whwre we MA have to go? about aquarter of MA has degree now. but ministry of health say, it not relevance … what is relevance for MA?
I think you should ask your association to fight for you guys.
already.. more than 10 years for that.
Dear Dr Pagavalan,
I am a junior MO from West Malaysia (WM) currently working in East Malaysia (EM) rural Health Clinic. Nearest referral centre is 4-5 hours of off-road journey (provided road condition is good) – that’s how rural it is.
Would like to give some of my thought on this topic, especially regarding situation in EM.
There is still a HUGE disparity between health care services in EM & WM, and efforts should be concerted to narrow the gap. Just to illustrate using an example: we are already beginning to see an oversupply of doctors in WM, yet in EM, still struggling hard to post even one MO to a rural health clinic (NOT klinik desa), which has a daily attendance of almost 200 outpatients!
Also, some KKs in EM actually offer emergency services, including deliveries, albeit with little support. Therefore, I actually do have on-calls even in KK setting, apart from the extra admin work (since boss is far far way)., and extra mobile clinics (up to 2 weeks in the wood).
So, good news for ‘PPP@klinik desa’, your service is still much needed here!
Anyway, amlodipine is now a list B item; and i can, with specialist consultation, give even list A* item eg Fortum.
Having said that, work here is satisfying really, and i learn just as much compared to housemanship training, in many other aspects though.
So, medical students/ junior HOs/MOs alike, if your really love your job and call yourself a ‘Dr’, please offer your service in EM especially district posting, rather than crying for papa & mama’s help to appeal when get posted to Sabah or Sarawak!
It such a disgrace remark to our profession by saying that we are acting like DOCTOR. It’s really painful to read yor article saying that we are not competent at our job. Do you have any idea how hard we are working? I ever fall into tears while trying to safe one teenager’s life where i didn’t have adequate equipment and what i could do beside resuscitating him was just praying in tears all the way to the nearest hospital. Then when I arrived at the hospital what kind of ‘greeting’ received? Blamed! Why didn’t do this, why didn’t write this and that. Because of this i ever thought that it seems like writing excellent referral letter is more important than patient’s life.
Do not simply come into conclusion that all new batch of MA is useless. This kind of articles really demotivating us.
You are in Sarawak, I presume. The situation there is very much different than in Peninsular. I am talking about Peninsular Malaysia. You can come and see for yourself.
Malas aku nak baca sangat
Tapi bab nak Ma berlagak nak jadi Dr aku pantang sikit la
Aku kejer d PH 18 tahun
Time raya Melayu… aku la stanby nya
Time Depavali aku la stanbynya
Tapi engkau punya regu baik jerr lari balik raya
Jangan kata Dr Cina raya Tahun Baru… Raya Korban pon disebat sekali
Klu refer kes banyak sikit… muncung sampai llutut
Tapi lepas waktu pejabat x malu pula dok berebut parking kat GP
GP kat bandar Kemaman …. handlebkes MVa kerr
Klu bukan common cold
Kau nak cerita byak2 xpayah leh citer psl org lain
Crrita kau punya regu xhabiss
Kau tahu klinik 5 Mo senior…mtime raya tinggal juniaor PPP
Nak aku sebut
Please read All The topics written in this blog before commenting. Issues where MOs missing in action, passing the buck to MAs has been written many times! Please don’t read just 1 blog post and pass judgement
Whatever. Im one of that thousands medical students, What should we do? Ofcourse cannot stop studying medicine just like that,after years crazying to pass the bloody exams! Nothing we can do rite!? Goverment itself support us to pursue study in medicine, we never knew from the first place it would be like this.lambakan doctors. I think ur post all are about blaming and blaming and blaming. Can u give some ideas on how to overcome this problem? Or, u should be our ministry of health or ministry of education or smthing like that.
This shows that you have NOT read this blog in total. ALL suggestion and actions that can be taken has been discussed and written in this blog for the last 5 years. Unfortunately, we have a government that do not listen to professionals. Despite MMA and various people telling the government that we are heading into oversupply, the government refused to accept it till end of last year!!Infact even the Minister refuse to believe till last year! Now when it happens, they refuse to take the blame